Request For Student Reassignment/admission Of Nondomiciiary Student Form Page 2
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IV.
VERIFICATION OF SPECIAL NEEDS/MEDICAL OR OTHER HARDSHIP
Reassignment/admission is requested for this student based on special curriculum or medical needs or other
hardship. Please identify the special needs of this student and indicate why a new assignment is warranted.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________
_________________________
__________________
Signature of Physician/Professional
Specialty Area
Date
__________________________________________________________
____________________
Address of Physician/Professional
Telephone
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V.
VERIFICATION OF EMPLOYMENT/CHILD CARE
________________________________________________
___________________ ______________________
Name and Address of Father’s Employer
Employer’s Signature
Telephone
________________________________________________
___________________ ______________________
Name and Address of Mother’s Employer
Employer’s Signature
Telephone
________________________________________________
___________________ ______________________
Name and Address of Child Care Provider
Telephone
Date Service Began
_____________________________________
________________________________________________
Days and Hours of Care
Signature & Title (Relationship if any) of Provider
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THIS FORM MUST BE NOTARIZED
My signature below certifies that I understand that providing misleading, untrue, inaccurate, or incomplete information will
result in the denial of this application and, if discovered after this application is approved, will be grounds for rescinding
approval. I further understand that I am providing the information contained in this application under oath and subject to
penalty of perjury.
___________________________________________
___________________________________
Signature of Parent/Guardian
Date
Sworn to and subscribed before me this ___________ day of _____________________, ______________.
____________________________________ _______________________________
(OFFICIAL SEAL)
Signature of Notary Public
Printed/Typed Name of Notary Public
My Commission Expires: ________________
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DECISION
This request is __________ Approved
__________ Denied
_______________________________
____________________________________________
Date
Superintendent
The Stokes County Schools administers all educational programs and admissions without discrimination because of race,
religion, national or ethnic origin, color, age, military service, disability, or gender, except where exemption is appropriate
and allowed by law.
Failure to complete form in its entirety will result in a delay of processing.
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