ADOPTED: 4-12-00 WAYNE CENTRAL SCHOOL DISTRICT
(continued....)
Exhibit 5151-E-3
Page 1 of 2
11) lf this student will reside in the Wayne Central School District, but not with his or her parent(s) or guardian(s), please indicate with whom he or she will reside?
NAME(s) ADDRESS
……………………………………………………………………………………………………
PHONE: (Home) ………………………..(Work)…………………………………….
12) Date whenthis student ceased or will cease to reside with his or her parent(s) or guardian(s) or will begin residence with the person(s) noted in Item 11, above: …………
13) How long will this student reside with the person(s) noted in item 11, above? ……….
14) Will this student reside in the home of his or her parent(s) or guardian(s) at any time during the following periods:
During the Week On Weekends During School Recess Periods
IF YES, when & why? ……………………………………………………………..
15)
Please indicate as fully as possible the reasons why this student will no longer reside with his or her parents:
PARENT(s) CERTlFlCATlON
I (we) hereby certify that: I (we) have relinquished all custody and control over the student named in Item 1, above, to the person(s) named in Item 11, above, including the right to make decisions pertaining to the health, welfare and education of the student If the student is permitted to attend Wayne Central School District, I (we) agree to promptly notify the Superintendent of Schools in the event that there is any change in the information provided
herein.
Signature …………………………………………………………..Date………………………..
Signature …………………………………………………………..Date………………………..
Subscribed and sworn before me on this day of ……………………………..., 20 ………
Notary Public…………………………………………
(Please Affix Stamp)
ADOPTED: 4-12-00 WAYNE CENTRAL SCHOOL DISTRICT
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