ࡱ> ~}_ +bjbjڿڿ 4~-b-bl#2 ^^^^^rrr8Lr#*("888&#(#(#(#(#(#(#$%(L#^L#^^88a#F^8^8&#&#!"8 $>.!#w#0#!,))"")^2"^LAfL#L##) B $: Wisconsin Department of Public Instruction APPLICATION FOR PART-TIME PUBLIC SCHOOL OPEN ENROLLMENT PI-9412 (Rev. 07-18)INSTRUCTIONS: Fill out all information completely and accurately. Missing or inaccurate data may hinder processing or result in errors relating to acceptance/denial. Deliberately providing false data may be grounds for denial of the application. Submit completed form to the district administrator of the nonresident school district.School Year___________ Collection of this data is a requirement of s. 118.52, Wisconsin Stats.I. GENERAL INFORMATIONTo be completed by the parent, legal guardian or pupil (if age 18 or older) and submitted to the nonresident school district. The application must be received in the nonresident school district office no later 4:00 p.m. on the date that is six weeks before the scheduled start of the course for which the pupil is applying. A postmark does not constitute timely submission.Pupil Name Separate application form is required for each pupil Email AddressTelephone Area/No.Grade ( 9 ( 10 ( 11 ( 12Residence Street AddressCity WIZip CodeSchool District in which the Pupil Resides (Resident District) or District of Attendance for Open Enrolled PupilsPublic School Pupil is Currently AttendingSchool District in which the pupil is applying to attend a course or courses (Nonresident District)If the pupil wishes to attend the course in a specific school in the nonresident district, indicate the name of the school. Note: assignment to a specific school for the course is not guaranteed. Name of the Course or Courses the Pupil is Applying to Attend 1. 2.Course Number if applicable 1. 2.Scheduled Course Start Date 1. 2. Yes No 1. ( ( Does the pupil currently receive special education in accordance with an individualized education program (IEP)? 2. ( ( Has the pupil been expelled any time during the current or preceding two years? 3. ( ( Are disciplinary proceedings pending that could lead to expulsion? Transportation: Parents are responsible for transporting the pupil to and from the course that the pupil is attending. If the parent is unable to pay the cost of transportation, the parent may apply to the Department of Public Instruction (DPI) for reimbursement of the transportation costs. The DPI must give preference to pupils who meet the income criteria to be eligible for a free or reduced price lunch. Wis. Stat. 118.52(11)(b) Will you be applying for the transportation reimbursement: ( Yes ( No If yes, you must submit an online claim for reimbursement of transportation costs (PI-9413) to the DPI at the end of the school year that the pupil attends a course. The online claim form will be available on our website starting June1 at  HYPERLINK "https://dpi.wi.gov/oe" https://dpi.wi.gov/oe.II. PARENT SIGNATURE AND RELEASE OF RECORDSNote to parent: Your signature on this form grants permission for the resident school district to provide the pupils transcripts as necessary to determine whether the pupil is a high school pupil and whether the pupil meets the nonresident districts prerequisites for the course. Further, s. 118.52 (10), Wis. Stat., authorizes the nonresident school district to request any pupil records relating to expulsion. This consent is effective until the pupil completes the course or until the application is withdrawn by the parent. Signature of Parent/Guardian or Pupil if 18 or older (Parent/Guardian Name Please printDate SignedIII. FOR SCHOOL DISTRICT USE ONLYThe cost of providing a course to a pupil shall be determined by first dividing the total number of hours of instruction provided to the pupil in the course by 1,137, then multiplying the result by the annual tuition rate as determined by s. HYPERLINK "http://docs.legis.wisconsin.gov/document/statutes/121.76(2)(a)" \o "Statutes 121.76(2)(a)" 121.76 (2) (a), Stats. For purposes of determining hours of instruction for virtual charter school coursework, the total number of hours of instruction shall be 135 hours per credit.Nonresident school district must send a copy of the completed form to the resident school district. IV. NONRESIDENT SCHOOL DISTRICT APPROVAL/DENIALTo be completed by the nonresident school district and sent to the parent no less than one week before the scheduled start of the course (a postmark of at least three days before the parent is required to receive it shall constitute timely notification).Name of Course ( Approved School at which the pupil will attend the course: ( Denied Reason for Denial: Required ( Space is not available in the course. Pupil does not meet the school districts policies and criteria for entrance into the course. Ineligibility: The application was submitted less than 6 weeks before the start of the course; the pupil is enrolled in private school or homeschool; or the pupil is not in a high school grade.Name of Course ( Approved School at which the pupil will attend the course: ( Denied Reason for Denial: Required ( Space is not available in the course. Pupil does not meet the school districts policies and criteria for entrance into the course. Ineligibility: The application was submitted less than 6 weeks before the start of the course; the pupil is enrolled in private school or homeschool; or the pupil is not in a high school grade.Name and Title of Nonresident School District OfficialSignature (Date Signed Mo./Day/Yr. V. RESIDENT SCHOOL DISTRICT OR DISTRICT OF ATTENDANCE DENIAL AND NOTICE OF NOT MEETING HIGH SCHOOL GRADUATION REQUIREMENTSTo be completed by the resident school district or district of attendance and sent to the parent no less than one week before the scheduled start of the course (a postmark of at least three days before the parent is required to receive it shall constitute timely notification).Name of Course ( Approved ( Denied Reason for Denial: Required ( The course conflicts with the pupils individualized education program (IEP). ( The cost of the course constitutes an undue financial burden on the resident school district. Ineligibility: The application was submitted less than 6 weeks before the start of the course; the pupil is enrolled in private school or homeschool; or the pupil is not in a high school grade.Name of Course ( Approved ( Denied Reason for Denial: Required ( The course conflicts with the pupils individualized education program (IEP). ( The cost of the course constitutes an undue financial burden on the resident school district. Ineligibility: The application was submitted less than 6 weeks before the start of the course; the pupil is enrolled in private school or homeschool; or the pupil is not in a high school grade.Name and Title of Resident School District or District of Attendance OfficialSignature (Date Signed Mo./Day/Yr. ( The course does not meet the high school graduation requirements in the resident school district or district of attendance. NOTE: This notification is provided for the pupils/parents information. Whether the course meets the high school graduation requirements is not grounds for denial by the resident district.( The course does not meet the high school graduation requirements in the resident school district or district of attendance. NOTE: This notification is provided for the pupils/parents information. Whether the course meets the high school graduation requirements is not grounds for denial by the resident district.VI. NOTICE OF RIGHT TO APPEALIf the pupils application is denied by either the resident or the nonresident school district, the pupil or parent may appeal the denial to the Department of Public Instruction within 30 days of receipt of the notice of denial. The appeal may be in the form of a letter or a legal brief and shall state the decision being appealed, the specific reasons for the appeal, including why the appellant believes the school boards decision was arbitrary or unreasonable, and any other facts relevant to the appeal. The appeal shall be signed by the appellant or the representative of the appellant. A copy of this completed form must be included with the appeal. The Departments decision is final and may not be appealed to circuit court. The appeal should be sent to: Open Enrollment Consultant, School Management Services, Department of Public Instruction, PO Box 7841, Madison, WI 53707-7841VII. NOTIFICATION THAT PUPIL WILL/WILL NOT ATTEND COURSETo be completed by the parent and a copy provided to both the resident and nonresident school districts no later than the last week day (excluding state holidays) preceding the scheduled start of the course.________________________________________ (Name of Pupil) ( will ( will not attend ___________________________________ (Name of Course) ________________________________________ (Name of Pupil) ( will ( will not attend ___________________________________ (Name of Course) Signature of Parent/Guardian or Pupil if 18 or older (Date Signed Mo./Day/Yr.     Page  PAGE 2 Pupil Name: PI-9412 -etuz ) , - D F w | w |   & ' ( * + , / 0 1 4 5 6 9 : X Z d e ƹơơơơƕӎϊh#X h 5CJ h;:+CJ h;:+CJ jqh;:+CJho!f h\h;:+h\hph;:+6 h;:+6h;:+ h 5hy&h h CJ hy&6CJ h)&CJ hy&5CJ hy&CJjhy&U6-ezr Ekd<$$Ifl4F0* `:0    4 lalyt1$x$Ifa$gdy& $x$Ifa$ $Ifgd)& $Ifgdx,$If * + , - D E ]WQW$If$Ifxkd*$$Ifl4-00* :04 lalyt\$x$If^a$gdt ($Ifgdt xx$Ifgd;:+E F RE $<$Ifa$kd$$IflF0*  0    4 lalpyt%;  & / 9 yqbb <d8($If($If$If]^gdo!f $Ifgd\$Ifakd$$Ifl0*0*04 lalyt%;9 : S X [ d b\TI\ $($Ifa$x$If$Ifkd$$Ifl\#0*@ T04 lalyt%;d e  uoo$IfkdX$$IflFx#0*xd T0    4 lalyt%; % P f n s PU5;<=>GL?D %WYtuv'1<KZƽ hOB6h4f0 h 6hOBh#Xht h CJ jqh CJ h CJ h 5hy&h hy&h J  g -uk $If ($If $$Ifa$vkd$$Ifl0x0*x04 lalyt%;-.lorxlxx P$If]x$IfP$Ifvkd$$Ifl0x0*x04 lalyt%; 8uiT< &>vd$If &>v$If V$Ifkd$$IflFx!0*x+ 0    4 lalyt%;~t`U P$IfgdOB 4B .P$IfgdOB (P$Ifckd$$Ifl0*0*04 lalyt%; &>vd$Ifgd Zdi|123C\y PoEFGglm|}uݟ(hy0JB*aJfHphq .hyhy0JB*aJfHphq  jh CJ h 6h#Xh1h\ h 5 h 5CJ h CJh,hOB0JjhOBUhOBhy&h 412$If$Ifckd;$$Ifl0*0*04 lalyt%;23FRG x$Ifgd1kd$$IflF` `0*`   0    4 lalpyt%;FG|~$If($Ifx$Ifakd $$Ifl0*0*04 lalyt%;uoio$If$Ifkd!$$Ifl0F$0*u0    4 lalyt%;RD$($Ifa$gdykdN"$$IflF0*  0    4 lalpyt%;,-;<JKLP[\|~˞˄~ul~hd`h~[Q[L[hGh h >* ho!f6h8dh 56 h 6hdQh8dh h4f056CJh 56CJ h CJ2hyh B*OJQJaJfHphq (hy0JB*aJfHphq .hyhy0JB*aJfHphBiq .hyhy0JB*aJfHphq 7jhyhy0JB*UaJfHphq KL|}{ $$Ifgd&Ny $$Ifgd&Ny $(a$gd&Nyckdz#$$Ifl0*)*04 lalyt%;}~~R@$$$Ifa$gd&Nykd$$$IflF 7* =8  0    4 lalpyt[~#d V>d$If^`>gdo d$Ifgdd$Ifgdd$Ifgdo d$Ifgd:kdJ%$$Ifl7*7*4 lalyt[#($DSTUVWuzG  '7@AJKLMXYdfѷѦhh8d6CJ hZh8d jhZh8d htCJhh8d5CJ h8dCJhhZ h 5 h >*hy&h h CJ jqh CJA#DU`g a7d$If^`7gdo hdd$Ifgdd$Ifgdd$Ifgdo d$Ifgd & F Vd8(($If^gd & F Vd8($If^gdo G  AKMefyl_VIV (<$Ifgd*V $Ifgd*V (P$Ifgd*V (<$IfgdoMkd%$$Ifl0rN*r4 lalyt[ & F ad8(($If^gd & F ad8($If^gdofgheYIY$$($Ifgd&Ny $$$Ifgd*Vkd&$$Ifl(Fr"7*r 0    4 lalpyt[fgh/   4=>?@^cS X h !!F!G!H! """;"D"I"i"|"""" htCJhh8d5CJhhy& h8d5 h8dCJ jqh8dCJ h8d>* h&Ny6h8dh8d56 h8d6hlcdh[ h8dCJh8dARB$$Ifa$gd&Nykd&$$IflF"7* 0    4 lalpyt[ !> u__I & FdL($If^gdlcdd8($If^`gdlcdd($If^`gdlcdd$If^`gdlcdd$Ifgdo x$Ifgdo:kd($$Ifl7*7*4 lalyt[ F!!i"k & FdL($If^`gdlcddL($If^`gdlcdd8($If^`gdlcdTd($If^Tgdlcdbd$If^b`gdd$Ifgdo dx$Ifgdoi"j""""""re\O\ (<$Ifgd*V $Ifgd*V (P$Ifgd*V (<$Ifgdlcdkd`($$Ifl0r7*m04 lalpyt["""""""""""""""@#Z#]#c###$$$$$$$$$$[%\%]%^%|%}%%%%%\(((((())5)6)7)*:*ϼϰϼϰόόϼϼόχ h8d6hy&hh8dCJaJhy&6CJaJh8dh8d6CJaJh8dh8d5CJaJhlcd h8dCJ jqh8dCJh8dhh8d6CJ hZh8d jhZh8d h8dCJ htCJ hCJ5""]#$$eO>$$V$If]^V`a$gdl ($Ifgdt$V$If^V`a$gdlkd )$$IflgFr"7*m 0    4 lalpyt[$\%]%^%|%}%pjdj$If$Ifkd)$$Ifl0r7*m04 lalpyt[ $Ifgdl}%~%(((yj/)$If:kd}+$$Ifl7*7*4 lalyt[ $Ifgdlcdkd*$$IflF@ 7*@ @      4 lalpyt[(5)6)7)*m]$$Ifa$gdokd+$$IflF 7*       4 lalpyt[$If$If**A*T****++IOkd,$$Ifl0`7*`4 lalyt[$x<$Ifa$gd*V $Ifgd$x$Ifa$gd*V:kd,$$Ifl7*7*4 lalyt[:*?*A*B*C*I*J*K*********;+@+A+P+Q+R+]+^+i+k+l+m+o+p+r+s+u+v+x+}+~+++++++~uhy&0J5CJjht0JCJU*h0JCJmHnHu*ht0JCJjht0JCJU htCJhQjhQUh htht6ht h*Vh8d jh*Vh8dCJ h8d6 h8dCJ jqh8dCJh8dhy&*+P+R+j+k+l+n+o+q+r+t+u+w+x+ $da$gdlOkdl-$$Iflg0X 7*X  4 lalyt[ $Ifgd $Ifgd <$Ifgd*V +++++++h hQht htCJht0JCJht0J5CJx+++++ $da$gdl  !0*(2 00&P/ =!"#$%h <Dd8ZR  C .Alogo_formsb~ں`crDnj~ں`cPNG  IHDR.bssRGBgAMA a cHRMz&u0`:pQ<PLTE  !!!"""###$$$%%%&&&'''((()))***+++,,,---...///000111222333444555666777888999:::;;;<<<===>>>???@@@AAABBBCCCDDDEEEFFFGGGHHHIIIJJJKKKLLLMMMNNNOOOPPPQQQRRRSSSTTTUUUVVVWWWXXXYYYZZZ[[[\\\]]]^^^___```aaabbbcccdddeeefffggghhhiiijjjkkklllmmmnnnooopppqqqrrrssstttuuuvvvwwwxxxyyyzzz{{{|||}}}~~~]} pHYs.#.#x?vtIME%(&tEXtSoftwareAdobe Photoshop CS4 Macintosh<qIDATx^yxE; GC6K%@"K1+r+ TC]YCY.p9FP B# $BdfW5O׊WSmWm֡4{G#9g9¶p}: ai ax#/i/`0%BmDtk|?@pm$C 3J4 PQnD <}#r{}"{2›-^ -<,`PgB d9Kvx@%f Ÿ C%Vd#e J쫟 PI@_rﱐp#,  Y-a$%n-aޮ--U$LLHT&gp8|z'*aʆgҷOk&HxZHcC ,@a[<:=XJvX`Ns>U+^ȳ{O+E}fT[Cq2k͢0ŕT8͹D|UJ=\C#tM/hE8B &\ߙCG4:a Jf>"!tU:M,"TgDteCLPhVEH, #l媲eMn:6hƊ:vcM hmbfʳ37kpGMxMk2'A)Ӫ[)dIa~<5D9m tH$BeVN |Rxncc1ɍ/P&e0DB9ff̙Y%W@&'Һi>+W,T.}WϧdKn/AZ*:,hdB}"#9yC@,XL"(ޓPWygL<աAG!tGly]OyQRz+0], ҠSb, =IMUCV{ (zpPNdg(q 0ehtWwtzz3dz6!z~_|vX7?u^!pߛk.QFG"=5,U[:LD;魸+PyY+un-Fu:5o4ngF7 b4Hwǻ(JGѡwHEtnw[%( N/hV@<MH6ܳs(l]}FkJtMu%x&Bm?=*?3}9x!5A.Oj)*r];b$۸zSth F{ 5h.Е~cbWxS9OƾإUHMe4f};[B5k~:4ܽRQKRmIxR~IEc]!ntA͗!hu~e>us_Йus9B7F8cWcARыrAd@_C tVSpA8m65C\ ?ɀ5 %@{E;b$ĒCMWhap q+DzESGڧKJV@nNs1#$v$`}L+~O8c`]_7>RM?PudV׺@B#aV^%EEG1>bT:;D,| y <,Q,t3X:\0Bzp-љn$آktKQKP<% F7Pe|x nJWe#[tc  Y2 !}Cw^sC GE/Nr )[_}-y$^1u@!=b̀˱:+wb|s'T#'қh.f':zCY% Q3@5lA9EZ`1-3NdU}dJFCO 6ly]"t Azp;(tD++-KD ]:e$TՙlO y7)-l)GX#'Q̄.VDO_r")Hͫ)+^ũr3"=LizPc} v+WGPD̋йT=pE|S O0`,ΝL:SAhn~k1 b$ZĚL꾁nw%:.euI#aTd]7+bZ=,'#+ Ky7Ο0k6})wT| RotьTքuH`+POgR v7Z鵋? *ǿRYy $OY8kѸ].g)gO}eפ-6c)07ұi[V0r4{ӍkF˒&[BHr/9'ڲb}n۶mο&}NӪnK[ 7o,M p'D4[3tKƏ~C?Dnעe˦k`ڈ,Kݷr.ȚP'lwM{7YOMHWnKlEXLDHEfV}JNI"}Dk?#T1XKD42rYz֩ |!d'Fgmn`+Ȅo:T 6M;d?Bވ݀?\㇄9-ۮ6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ y&NormalOJQJ_HmH sH tH DA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List HB@H $W= Body Textd  CJOJQJDOD HEADING$ P<a$5POP y& Table Heading$(a$ CJOJQJLO"L $W= Table Text$dxa$ CJOJQJ4@24 Header  !4 B4 Footer  !.)@Q. Page Number6U`a6 OB0 Hyperlink >*B*phcHrH ;:+0 Balloon TextCJOJQJ^JaJN/N ;:+0Balloon Text CharCJOJQJ^JaJ"o" yqsrunPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<v #~ 1111114 Zf":*++"(,05;= E 9 d  -2F}~#f i""$}%(*+x++ !#$%&')*+-./12346789:<> ,;#XX4!8@0(  B S  ? ))))))))) PP\(#! [kk'77#9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType8 *urn:schemas-microsoft-com:office:smarttagstime 016HourMinute l#n#o#q#r#t#u#w#x###  k#l#}###tut t    y y o o k#l#}#####tut t    y y o o k#l#n#o#q#r#t#u#w#}#####@uP^`CJOJPJQJ^Jo(q^`OJQJ^Jo(hHoaa^a`OJQJo(hH1 1 ^1 `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hHqq^q`OJQJ^Jo(hHoAA^A`OJQJo(hH@uzy        !4?ABCDEFGHIJKLMNOPQRSTUVWYZ[\]^_`abcdefghijklnopqrstvwxyz{|Root Entry FG@Data @.1TableX)WordDocument 4~SummaryInformation(mDocumentSummaryInformation8uMsoDataStore@/ $>MC00BGE4S3==2@/ $>Item  2PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q