Office Use Only
Date Rec’d ___________
Time________________
By__________________
Student ID#__________

Licking Valley Local Schools                          
2019-2020 Open Enrollment Application

_____Renewal Application		_____New Application
(Deadline is April 1, 2019)			(Deadline is May 31, 2019)
		
Student Name: ___________________________________ DOB: _____________ Gr. Level 19/20 school year: ______
	Male____   Female____		District of Legal Residence: ____________________________________________
					Last School Building Student Attended: __________________________________
	
	Name of Custodial Parent/Guardian: _________________________________________________________________
	Mailing Address: _________________________________________________________________________________
	Physical Address: ________________________________________________________________________________
				(Only if different than mailing address)

	Home Phone: _____________________ Work Phone: ____________________ Cell Phone: ____________________
	Reason for request: ________________________________________________________________________________
	________________________________________________________________________________________________
	Name and grade level of other siblings enrolled or requesting Open Enrollment in Licking Valley Local Schools:
		Name:  _____________________________________________		Grade: ________
		Name:  _____________________________________________		Grade: ________
		Name:  _____________________________________________		Grade: ________
	
	1.  Has this student been expelled or suspended for 10 or more days during the preceding school year?	 __Yes   __ No
	2.  Will this student be attending C-TEC (Career & Technology Education Center of Licking County)?	 __Yes   __ No
	3.  Does this student’s education program include an IEP or 504 Plan?					 __Yes   __ No
	4.  Are you requesting transportation within the boundaries of the Licking Valley Local School District?   	 __Yes   __ No
	5. Are you a Licking Valley graduate? 						__Yes  __No 	Class of: _______
	6. Is your spouse a Licking Valley graduate?						__Yes  __No 	Class of: _______

•	All new applicants must attach a complete immunization record, birth certificate, a recent official transcript or record of achievement, a current IEP for special education and a record of any suspensions or expulsions from the current and/or previous school term. If you are an appointed guardian or the custodial parent for school purposes, please attach the appropriate court documents. All forms MUST be attached to be considered. Qualified applicants will be admitted based on building, grade level, and program capacity. All students must be registered in their resident school district (where you live.) Falsification of information will result in the rejection or termination of transfer.                                                                                        		*Renewal applicants do not need to attach the above information.

As stated in the Administrative Guidelines, Licking Valley Local School District is not responsible for providing bus service to students attending under the Open Enrollment Policy. The District may consider transportation only within district limits or if space on bus is available. Please note that you must apply for Open Enrollment each year and approval is based on student/teacher ratios and other criteria stated in the guidelines. Qualified applicants will be admitted based on building, grade level and program capacity. The district will notify you, in writing, of approval or denial of this request.

	Pick-up/drop-off address: __________________________________________________________________________
	Name of Family/Daycare: __________________________________________________________________________

	Signature of Parent/Guardian: _____________________________________________ Date: ________________
	  
•	Return this form to:	Licking Valley Local Schools
District Office/Open Enrollment
1379 Licking Valley Rd. NE, Newark, OH 43055
	>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>OFFICE USE ONLY>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>	
	___Approved	___Disapproved		
Principal’s Signature: _________________________________________________________   Date: ____________________

Reasons: _____________________________________________________________________________________________
	
	Superintendent’s Signature: ____________________________________________________ Date: ____________________