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Out of District Waiver Request
This form is for non-resident student enrollment for the 2017-2018 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.
Student's Last Name
Your answer
Student's First 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 2017-2018
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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