PRIMARY REASON FOR REQUEST: Check ONLY ONE …

1 Date: School Year: School District of Manatee County OFFICE OF STUDENT ASSIGNMENT. 1400 1st AVENUE E PALMETTO FL 34221. PHONE (941) 708-4971 FAX (941) 708-4976. HARDSHIP REQUEST FORM. SCHOOL BUS TRANSPORTATION WILL NOT BE PROVIDED. The Administrative Review Committee may consider statements submitted in support of the hardship request. Completing a hardship request form does not guarantee approval. School Wanting to Attend: Student Last Name: Student First Name: Date of Birth: Gender:_ Grade Level: Phone No. Current Address: Apt.#: City: State: Zip Code: Parent Email Address: Student Social Security #. (Section ). All new students to Manatee County must present a birth certificate and must answer both questions: 1. Is student of Hispanic, Latino or Spanish origin? Yes No 2. Race: ( Check all that apply). White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Brother/Sister applying for hardship to same school: Name: DOB: Grade PRIMARY REASON FOR REQUEST: Check ONLY ONE REASON that applies Attachments Acceptable A.

2 Before/after school childcare issues B. Medical Must attach documentation of condition requiring change of school placement C. Moved and want to remain at the school E. Moving and want to start at new school must provide copy of contract or lease F. Safety Reasons Must attach documentation of safety issues G. School District Employee Site Name : H. School near parent's work I. School Grade at zoned school J. School Staff issues at zoned school (principal, staff, etc.). K. Transportation Issues L. Program offered at another school (magnet, HS Academy, gifted, arts, etc.). M. Sibling is already attending the school: Name: DOB: Grade: O. Other- Explain Please note current school may be consulted. If approved, I understand that the principal at my child's hardship school assignment may recommend that this be revoked for any of the following reasons: . Poor Attendance . Tardiness Conduct disruptive of the learning environment When a student is approved for a hardship based on a specific academic program, the principal may recommend that the student be returned to the home school if he/she fails to participate successfully in that program.

3 Enrolling Parent/Guardian Signature (only 1 parent is the Enrolling Parent). Please Print: Parent First Name: Parent Last Name: For Office Use: Approved/Denied Zone: Attendance: Ex: Unex: Tardy: Disc: ESE: Current/Last School Attended: Letter Sent: Focus: E /T. Rev: 10/2017sac