USD 495 Out of District Transfer Request Form
If you are requesting out of district transfer for more than one student, a separate form must be completed for each student.
Date of Request
MM
/
DD
/
YYYY
Parent/Guardian Name(s)
Your answer
Current Street Address
Your answer
City
Your answer
State
Your answer
Zip/Postal Code
Your answer
Phone Number
Your answer
Current District of Residence
Your answer
Student First Name
Your answer
Student Last Name
Your answer
Student Date of Birth
MM
/
DD
/
YYYY
Current or New Student?
School Attended Last Year
Your answer
School Requesting to Attend
Your answer
Grade Level
Your answer
Explanation for Transfer Request
Your answer
Signature to Certify Information is Accurate
Your answer
Submit
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