RELEASE FROM IREDELL - STATESVILLE SCHOOLS
P.O. Box 911 / 549 North Race Street, Statesville, NC 28677
Phone (704) 872-8931, Fax (704) 871-2834
Please complete and mail form to the attention of Joy Dorty, 549 N. Race Street,
Statesville, NC 28677. If the top portion of the form is not complete it will be mailed
back to you for completion and will delay the release process.
Student’s Name
Present School
_______________Grade ______________
______________________________
Requested School System _____________________________
New Application______
Effective for the
Release to the
Renewal
_______________________ school year
__________________________________________
A formal letter explaining in detail reasons for this request should be attached to this completed application.
All approved requests are granted without benefit of transportation, books, or other fees/materials, or other
Releases are granted for one
school year only and must be renewed each year.
costs incidental to the student’s enrollment in another system.
A copy of your approval should be submitted with a written request to the
superintendent of the system to which you have applied.
Address
________________________________________________
City
_________________Zip Code _________________
Home Telephone _________________________________________
Business Telephone _______________________________________
Parent/Guardian Signature
Date
For Office Use Only
Date _____________
The Iredell-Statesville School Board releases ___________________from the
educational jurisdiction of the Iredell-Statesville School Unit for assignment to a
school in the ____________________________Unit for the _________school
term.
Signed:
Richard Armstrong Jr. – Assistant Superintendent - Operations