Wortham ISD
Texas Education Agency Division of Equal Education Opportunity
Application for Transfer FY 2
-
Authority for Data Collection: Texas Education Code 21:061; Civil Action 5281, Section A Planned Use of Date: To complete the report required by Federal Court Order Civil Action 5281. Instructions: This form must be used for all student transfers, within the State of Texas, including hardship. The Wortham ISD Superintendent must circle approved or disapproved and sign the transfer form. For further information, contact the Division of Equal Education Opportunity at (512) 463-9671.
Students Name
Soc. – Sec. Number
Sending Co. Student’s Receiving District Grade Campus Number Level No. Last First MI PEG SApprove d Superinte ndent’s Signature ________ ________ ________ ________ This section must be completed by parent or guardian: ________ _____ I have been informed of the Wortham ISD policy concerning tuition charges, if any, for a transferred student whose grade is taught in the student’s district of residence: I accept responsibility for the andDenied payment of tuition. I also understand that a transfer may be revoked atDate____ the discretion of the Wortham ISD Superintendent. Causes for revocation include, but are not limited to: excessive absenteeism, discipline ________ problems, criminal arrests or poor grades. ________ ________ Signed Phone Number (Parent’s _______ (Guardian’s) Signature) Ethnic Code
Street Address City
State
Zip
This section must be completed by the Wortham ISD Superintendent: Approved The above transfer(s) was/were
on this
th day of
2
Disapproved
Typed Name of Wortham ISD Superintendent David R. Allen
Date
Telephone
254-765-3095
Signature
.
Application for Transfer FY 2
-
Authority for Data Collection: Texas Education Code 21:061; Civil Action 5281, Section A Planned Use of Date: To complete the report required by Federal Court Order Civil Action 5281. Instructions: This form must be used for all student transfers, within the State of Texas, including hardship. The Wortham ISD Superintendent must circle approved or disapproved and sign the transfer form. For further information, contact the Division of Equal Education Opportunity at (512) 463-9671.
Students Name
Soc. – Sec. Number
Sending Co. Student’s Receiving District Grade Campus Number Level No. Last First MI PEG SApprove d Superinte ndent’s Signature ________ ________ ________ ________ This section must be completed by parent or guardian: ________ _____ I have been informed of the Wortham ISD policy concerning tuition charges, if any, for a transferred student whose grade is taught in the student’s district of residence: I accept responsibility for the andDenied payment of tuition. I also understand that a transfer may be revoked atDate____ the discretion of the Wortham ISD Superintendent. Causes for revocation include, but are not limited to: excessive absenteeism, discipline ________ problems, criminal arrests or poor grades. ________ ________ Signed Phone Number (Parent’s _______ (Guardian’s) Signature) Ethnic Code
Street Address City
State
Zip
This section must be completed by the Wortham ISD Superintendent: Approved The above transfer(s) was/were
on this
th day of
2
Disapproved
Typed Name of Wortham ISD Superintendent David R. Allen
Date
Telephone
254-765-3095
Signature
.
