Transfer Request Form
Date of Request:
/
Month
/
Day
Year
Date
Student:
First Name
Last Name
Grade:
Please Select
PreK
K
1st
2nd
3rd
4th
5th
Current School:
Please Select
Harper
Jerger
Scott
Parent/Guardian:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone: (Home/Cell)
Format: (000) 000-0000.
Phone: (Work)
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred School:
Please Select
Harper
Jerger
Scott
Receiving Special Ed. Services?
Yes
No
Services Receiving:
Speech
Gifted
MIID
MIOH
SED
EBD
Other
If Other is marked above, please list the services you are receiving:
blanks
Reason for Request(If you moved, please provide proof of address)
*
Parent's/Guardian's Signature:
*
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: