Exhibit

Student Services and School Attendance
1465 David E. Cook Way Clovis, CA 93611-0574 Phone: 559-327-9200 Fax: 559-327-9222

No. 2202 (6)

DIGMAC # __________

SID # _______________

ANNUAL EMPLOYMENT VERIFICATION

ili	l	l	r .
l	t rit i t i	r	.
Mailing label goes here. Please do not write in this area.

Completed applications must be returned to the Office of Student Services and School Attendance.

PLEASE PRINT:

Today’s Date:	

Requested School Year:	

Resident School District:	

Parent/Guardian Name:	

Address:	 City:	 Zip:	

Home Phone:	 Work/Cell Phone:	 Email:	

I request permission for my child(ren) listed below to attend the Clovis Unified School District due to parent/guardian employment. Education Code section 48204(b)

STUDENT’S LAST NAME
	STUDENT’S FIRST NAME
	
DATE OF BIRTH
	
REQUESTING GRADE
	SPECIAL ED. STUDENT YES/NO
	SCHOOL REQUESTED
	RENEWAL YES/NO

							

PARENT CERTIFICATION: I have read and understand all the transfer stipulations listed on the back and verify all the information provided is correct. I understand that if the information proves to be incorrect through error, omission or misstatement, my transfer application may be denied. My signature below indicates my understanding that the sending and receiving school district may request student records before this transfer is processed.
Signature of Parent/Guardian: _______________________________________________________________ Date: ________________________

PLEASE ATTACH A COPY OF CURRENT PAY STUB SHOWING EMPLOYER NAME AND ADDRESS

(Please delete information not needed to verify employment)

EMPLOYER:
	PHONE NUMBER:
	
ADDRESS/LOCATION:
	CITY:
	ZIP:

I verify that the above named person is employed as noted above:

Signature of Employer:	 Date:	

FOR DISTRICT USE ONLY	Date: _________________
Student:	
Requested School:	

DENIED: Your transfer has been denied for reason # 	
1. There is no space available at this time. 2. There is a documented safety concern.
3. Special Education services are not available or are impacted.
4. The reason for the transfer request does not meet Governing Board criteria.
5. There is no space available; a second choice school has been assigned. (See box on the right)
	
FOR DISTRICT USE ONLY	Approval Date: _______________
Student:	
Requested School:	

APPROVED: Your transfer has been approved for reason: 	
PE	Parent Employment
PW	Parent Employed within CUSD Boundaries

Effective Date:	Expiration Date:

PARENT INFORMATION – ACCEPTANCE PROCESS
This approved application and all enrollment documents must be presented to the approved school by 	 or the approval will be rescinded. All of the abovementioned conditions will apply once the transfer is accepted.

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PARENT CERTIFICATION FOR ANNUAL EMPLOYMENT

Please initial

_____	I will immediately notify the Director of Student Services and School Attendance of the Clovis Unified School District upon any change in employment status. The noted employer is authorized to release employment information to the Director of Student Services and School Attendance of the Clovis Unified School District and to the District of Residence as provided in this verification.

_____	 I understand this verification is valid for one year only and must be renewed annually by the District of Attendance and the District of Residence. Clovis Unified will initiate the verification process and provide documentation to the District of Residence.

_____	I understand that transportation is not provided by Clovis Unified School District and is to be provided by the parent/guardian/caregiver. All students are subject to capping and busing.

_____	I declare under penalty of perjury that the foregoing is true and correct. It is understood that, if upon review by both districts, any declaration contained herein is not verifiable to the satisfaction of the Director of Student Services and School Attendance of the Clovis Unified School District and District of Residence, all entitlements and benefits accrued by such declarations are void and the residence of the parent/guardian/caregiver will be deemed the residence of the student for school purposes.

_____	I declare under penalty of perjury that the foregoing is true and correct. It is understood that, if upon review by both districts, any declaration contained herein is not verifiable to the satisfaction of the Director of Student Services and School Attendance of the Clovis Unified School District and District of Residence, all entitlements and benefits accrued by such declarations are void and the residence of the parent/guardian/caregiver will be deemed the residence of the student for school purposes.

PARENT INFORMATION - ATHLETIC ELIGIBILITY

_____	Employment-Based Residency approvals do not grant athletic eligibility. Athletic eligibility for students in grades 7-12 is determined by the California Interscholastic Federation and Clovis Unified School District’s Board Policy No. 2505. If you wish to have your child participate in athletics, you must contact the Athletic Director of the receiving school to request athletic eligibility. Appeals for athletic eligibility will not be heard until after the student is enrolled and attending the requested school.

Adopted: Revised: Revised: Revised:

12/12/07 09/18/08 02/01/12 01/14/14

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