2023-2024 In-District Permit Application Form from Cedar Rapids Community School District

Refer to Procedure 602.4a to determine if your student requires / qualifies for a permit.

Resident School	Requested School	Year

School Currently Attending	Date of Application	Grade

Student:

Last Name	First Name	Middle Name

Birth Date	Gender	Special Education (IEP)
	Female Male	Yes No

Reason for Permit Request

Student has moved to a different school outside of their attendance zone and would like to continue at their current school.
Student will be attending requested school with a sibling.
Student requires a transfer for documented safety reasons.
Unique family circumstances.

Sibling Information:

Sibling Name	Current Grade	Current School

Name of Parent / Legal Guardian:

Parent Last Name	Parent First Name

Home Address:

Street	City	Zip

Parent's Contact Information:

Parent's Phone Number:	Parent's Email Address:

Proof of Residency

I understand that:

When a permit is approved, transportation becomes the responsibility of the parent / guardian. (Board Procedure 602.4a)

Athletic eligibility for high school students is restricted from the date the initial permit is effective. (Board Regulation 602.9)

Proof of Residency must be attached. This is retained with student records at the building. (Board Procedure 602.4c)

Permits may be revoked based on attendance, falsification of information, or at the discretion of a district official.

I certify that this information is true and correct
(to sign it type in your name and click 'Digitally Sign')

FOR ADMINISTRATION ONLY

District Administrator:	Approve or Deny:	Date Signed:
	Approved Denied

Signature:

Cedar Rapids Community School District - 2023-2024 In-District Permit Application Form