Annual Employee Application for CCPS Out of Zone School Attendance

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Applications MUST be received between January 15 and March 31 for the upcoming school year.
Applications received earlier than January 15 or after March 31 will be denied. Requests are acted upon on
a first-come, first-serve basis.

Employee Name *

Employee Position *

Work Location *

Employment Verification- Name of Supervisor

For School Year (Select one only) *

Child's Grade For School Year Indicated *

Child's Last Name *

Child's First Name *

Child's Middle Name

Child's Date of Birth *

YYYY

Parent/Guardian's Name *

Parent/Guardian's Address (Street, City, Zip) *

Home Phone (XXX-XXX-XXXX) *

Work Phone (XXX-XXX-XXXX) *

Cell Phone (10 Digits) (XXX-XXX-XXXX)

I am requesting permission for my child to continue to attend (requested school from below) *

Instead of school of home address *

Resident County and School OTHER than Culpeper County

Previous years attended at this school *

Reason for this request: *

If Child Care/Supervision the provider's name address and phone number must be provided below.

I am requesting my child ride a bus to and/ or from the child's care provider's residence/location.

Yes

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