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Parent/Guardian Signature Phone Date Limited School Choice LSC is a privilege provided by the Rockwood School District. LIMITED SCHOOL CHOICE REQUEST School Year for which the application applies In accordance with the Limited School Choice policy I request that my child ren be transferred Attendance Area School attendance area school Desired School only one school per application Student Names s Present Grade/School Year Full Day Present School Half Day For New Kindergarten requests Does this student have a sibling presently attending the new school of choice Reason for request YES NO Please print Parent/Guardian Name and Street Address on the three lines below. LSC is granted on a year-by-year basis students must reapply each year. A LSC transfer occurs at the beginning of a semester. Once a LSC transfer is approved the student must remain at the Choice school for a minimum of one semester. Extenuating circumstances will be reviewed by the school principal and the Assistant Superintendent of Human Resources. If a student s request is approved for Limited School Choice and the student is not successful in the Choice school the student may be denied his/her future request to return to this school after he/she completes the school year or semester. Prior to denial of the LSC request the parent and student will have a conference with the school principal* Choice Recommended Choice Not Recommended Comments Principal Signature Choice Approved With Transportation Choice Denied Without Transportation Superintendent/Designee Signature Form No* 2025 Date September 2013 Policy 2236 Page 1 of 1. LSC is granted on a year-by-year basis students must reapply each year. A LSC transfer occurs at the beginning of a semester. Once a LSC transfer is approved the student must remain at the Choice school for a minimum of one semester. Once a LSC transfer is approved the student must remain at the Choice school for a minimum of one semester. Extenuating circumstances will be reviewed by the school principal and the Assistant Superintendent of Human Resources. Extenuating circumstances will be reviewed by the school principal and the Assistant Superintendent of Human Resources. If a student s request is approved for Limited School Choice and the student is not successful in the Choice school the student may be denied his/her future request to return to this school after he/she completes the school year or semester. If a student s request is approved for Limited School Choice and the student is not successful in the Choice school the student may be denied his/her future request to return to this school after he/she completes the school year or semester. Prior to denial of the LSC request the parent and student will have a conference with the school principal* Choice Recommended Choice Not Recommended Comments Principal Signature Choice Approved With Transportation Choice Denied Without Transportation Superintendent/Designee Signature Form No* 2025 Date September 2013 Policy 2236 Page 1 of 1.

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