Out of District Waiver Request
This form is for non-resident student enrollment for the 2018-2019 school year. A waiver for each student must be submitted and approved each school year before September 1 to attend. More instructions will be included on subsequent pages depending on the type of waiver you select below. Virtual/On Site and Virtual Only applicants should be prepared to print or write down instructions we will give you on your next screen.
Email address *
Student's First Name *
Your answer
Student's Last Name *
Your answer
Last School Attended *
Your answer
Phone Number of School *
Your answer
Name of Student's Home School District & District Number *
Name of School District that you live in. EXAMPLE: Wichita, #259
Your answer
Grade Level for 2018-2019 *
Student's Date of Birth *
Your answer
Parent / Legal Guardian's Name *
Your answer
Home Phone Number *
Your answer
Cell Phone Number *
Your answer
Work Phone Number
Your answer
Street Address *
Your answer
City State Zip *
Your answer
Email Address for Notification *
Your answer
Please select one of the following *
Required
Name of School(s)
If student has previously attended Derby Public Schools, please list the name of the school(s) and years attended:
Your answer
Years Attended
Your answer
Reason for Request *
Your answer
What type of Out-of-District Waiver are you requesting? *
The deadline for Employee Children is July 1 or 10 days after employment
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