Request For Interdistrict Transfer Agreement Permit Form

This form is for residents of

SAN FRANCISCO UNIFIED SCHOOL DISTRICT

San Francisco who wish to

EDUCATIONAL PLACEMENT CENTER

School year 20____ - 20 ____

attend school in another

555 FRANKLIN STREET, ROOM 100

district.

SAN FRANCISCO, CA 94102

New Request______

Telephone: (415) 241-6085

Renewed Request______

REQUEST FOR INTERDISTRICT TRANSFER AGREEMENT PERMIT

Applying for

Student name_____________________________________________Birthdate_____________ Grade________ Race/Ethnicity_____

Last

First

Address _______________________________________________________________________Home Phone # __________________

Number

Street

Apt

Zip

Current School ______________________ Requested School ______________________ District requested____________________





Is student receiving Special Education Services or other Special Services?

Yes

No.







If yes, is student in

Resource Specialist Program

Special Day Class

Other___________________ I.E.P. must be attached

Reason for Request: ___________________________________________________________________________________ _________

______________________________________________________________________________________________________________

If request is for Childcare or Employment reasons, complete the following:

Childcare Provider _____________________________________

Employer Name______________________________________

Address_______________________________________________

Address_______________________________________________

City, Zip______________________________________________

City, Zip______________________________________________

Phone No:_____________________________________________

Phone No _____________________________________________

Work schedule_________________________________________

NOTE: IMPORTANT INFORMATION

1.

This Agreement covers only one school year. You must reapply annually.

2.

If an Interdistrict Contract has been signed by both districts, the district of attendance may reserve the right to revoke this permit for

any student whose behavior, citizenship, attendance and/or academic progress fails to meet their standards

MOTHER/GUARDIAN (print)____________________________ FATHER/GUARDIAN (print)____________________________

Work/Cell phone #____________________________

Work/Cell phone #_____________________________

PARENT/GUARDIAN SIGNATURE:___________________________________________________ Date_____________________

 District of attendance to claim ADA for revenue purposes (no tuition billed) for General Education students.

 For students receiving Special Education Services, an InterSELPA agreement will need to be signed by the SELPAs to which both the district

of attendance and the district of residence are members prior to this Interdistrict Permit’s approval.



If this student requires new or additional special education services, or change in service, subsequent to date of approval of this permit, SFUSD

MUST BE informed prior to the IEP meeting, and invited to the IEP meeting, and this permit will need to be reviewed.

FOR DISTRICT OF ATTENDANCE USE ONLY ONLY

This agreement, made and entered into this ______ day of _____________, 20___, pursuant to Education Code chapter 5, Section 46600, by the

Governing Board of the San Francisco Unified school District of San Francisco County, and the __________________________________________

School

District

of

_________________________

County

hereby

give

permission

for

the

above-named

pupil

to

attend

____________________________ school in the Second-named District during the school year ending June ______, 20____.

Taken by:________ Date:__________

HO#_______________________

District of Residence (S.F.U.S.D.)

District of Attendance:__________________________________

____________________________________________________________

____________________________________________________________

Signature (Authorized Official)

Signature (Authorized Official)

Title________________________________________________

Title________________________________________________

Date___________ Approve_________

Deny________

Date__________ Approve________ Deny________

Non-Discrimination Policy

San Francisco Unified School District programs, activities, and practices shall be free from discrimination based on actual or perceived race, color, ancestry, national origin, ethnic group identification, age, religion,

marital or parental status, physical or mental disability, sex, sexual orientation, gender, gender identity, or gender expression; or on the basis of a person’s association with a person or group with one or more of

these actual or perceived characteristics.

If you believe you have been discriminated against, immediately contact the school site principal and/or Executive Director of the Office of Equity, Ruth Diep, at (415) 355-7334 or diepr@sfusd.edu. A copy of

SFUSD’s uniform complaint policy is available upon request.





Reason for Denial:

Appropriate placement available in San Francisco

Other_________________________________________________________________

Distribution: White -SFUSD

Gold- District of Attendance

Pink- Parent (after signed by both districts)