Attend Area Exception Form_Attend Area Exception Form
Kimberly Area School District
School Request Form One Form Per Child Please
Request for School Year _____________ Current Grade
Student First Name
Student Last Name
Street Address
City
State
Assigned School:
JAN
SUN
WES
WDL
MAP
Mother_______________________________
Zip Code
Desired School:
JAN
Home Phone
SUN
WES
WDL
MAP
Father______________________________
Work Phone________________________________
Work Phone_______________________________
Cell Phone_________________________________
Cell Phone________________________________
email address:______________________________
email address:______________________________
Student has IEP:
Yes
No
Reason Requesting Change: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Parent Signature _______________________________________ Date___________________
Please understand: if your child currently is a bus student and your request is approved, the Kimberly Area School District will no longer be responsible to provide student transportation. Return to: Supt. Robert S. Mayfield, Ed.D. • 425 S Washington St • Combined Locks WI 54113 • FAX 920-788-7919
Request Approved
Date: ______________________
Request Denied
School Request Form One Form Per Child Please
Request for School Year _____________ Current Grade
Student First Name
Student Last Name
Street Address
City
State
Assigned School:
JAN
SUN
WES
WDL
MAP
Mother_______________________________
Zip Code
Desired School:
JAN
Home Phone
SUN
WES
WDL
MAP
Father______________________________
Work Phone________________________________
Work Phone_______________________________
Cell Phone_________________________________
Cell Phone________________________________
email address:______________________________
email address:______________________________
Student has IEP:
Yes
No
Reason Requesting Change: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Parent Signature _______________________________________ Date___________________
Please understand: if your child currently is a bus student and your request is approved, the Kimberly Area School District will no longer be responsible to provide student transportation. Return to: Supt. Robert S. Mayfield, Ed.D. • 425 S Washington St • Combined Locks WI 54113 • FAX 920-788-7919
Request Approved
Date: ______________________
Request Denied
