• FORM III DOE 7/06

    ELECTION TO ATTEND SCHOOL WHERE THE PARENTS ARE DIVORCED OR SEPARATED

    This agreement is prepared by the State Superintendent of Public Instruction, as required by Indiana Code 20-26-11- 3, to implement I.C. 20-26-11-2.5. Form III is to be used where the student’s parents are divorced or separated but live in different public school corporations. Form III must be signed by the parent with physical custody or by the student if the student is eighteen (18) years of age and competent.
     
    Student Information
    Name: (last)_________________________________ (first)_______________________________(mi)___________ (street)________________________________(city)_________________________(state)______(zip code)_______ (date of birth) _________________
     
    Last school corporation attended: __________________________________________________________________
    School corporation elected: _______________________________________________________________________
     
    Parent Information
    Mother:
    Name: (last) ________________________________(first)_________________________________(mi)__________ (street)____________________________________(city________________________(state)_____(zip code)______ (telephone) __________________________________(email)____________________________________________
     
    Father:
    Name: (last) ________________________________(first)_________________________________(mi)__________ (street)____________________________________(city________________________(state)_____(zip code)______ (telephone) _________________________________ (email) ____________________________________________
     
    Parent with whom the student will live:______________________________________________________________
     
    In order to make an election under I.C. 20-26-11-2.5, the parent or student, if the student is eighteen (18) years of age, understand and agree:
    • This form must be completed and presented not later than fourteen (14) days before the first student day of the school year to the school corporation where the election to attend has been made.
    • In order to make this election, one or both of the student’s parents must live in the school corporation where the election to attend has been made.
    • The election to attend the school corporation is effective for one (1) school year.
    • This form must be completed and presented to the school corporation or each subsequent school year.
     I affirm, under the penalties for perjury, that the foregoing representations are true.
     
    ___________________________________________                               ___________________________________________
    Name (printed) Parent with Physical Custody                                             Name (printed) Student (if 18 Years of Age) ________________________________________________                     ________________________________________________
    Signature                                                                                                      Signature
     
    ________________________________________                                     ________________________________________
    Date                                                                                                              Date
     
     
    Sworn and subscribed before me this _________ day of ____________________, 20_____.
     
    _______________________________ resident of _____________ County. Expires: ___________
                (notary public)
     
     
    Form Updated: 8/6/10