Parent Refusal to Attend the School of Origin
I, ____________________________________, understand that in accordance with
Parent/Guardian
federal guidelines of No Child Left Behind/McKinney-Vento that I am entitled to allow
my child to attend the school of origin* for the school year that I fit into one of the
following categories:

sharing housing of other persons due to loss of housing or economic hardship

living in a motel, hotel, campground due to the lack of alternative arrangement

living in emergency or transitional shelters

abandoned in a hospital or awaiting foster care placement

living in cars, parks, and public places such as abandoned buildings, substandard
housing or similar settings
I prefer for my child, ___________________________, to attend the school in the
attendance zone for my new residence. Therefore, I am denying any special
consideration that will allow my child to attend the school of origin. My child will be
attending ___________________________________.
__________________________________________
Signature of Parent/Guardian
_________________
Date
*The school of origin is the school your child attended when had a permanent
established address or the last school attended.
Revised: 12/11/12