Telephone Number If receiving school district / Telephone Number Receiving Residential Facility/Receiving Special Education Unit / Receiving School / Regular Amendment Date Receiving School / INFORMATION RELATIVE TO APPLICATION FOR STUDENT ATTENDANCE IN OUT-OF-STATE PUBLIC OR PRIVATE SCHOOL FOR SPECIAL EDUCATION Under Section / Applying School District of Residence Administrator Address / School District of Residence / exceeding school district / Telephone Number Special Education Unit / PRIVATE SCHOOL / Department of Public Instruction / resident school district / School Board of Public School / Applying School District of Residence / /
Position
Clerk / teacher / superintendent of public instruction / Administrator School Date SUPERINTENDENT OF PUBLIC INSTRUCTION APPROVAL / President / superintendent / State Superintendent of Public Instruction / Administrator / /
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