Page 1 of 2ORIGINAL - Choice and Career OptionsPBSD 2580 (Rev. 4/10/2018)

STUDENT FIRST NAME GRADE APPLYING FOR BIRTH DATEPBCSD STUDENT ID# (if applicable)

ADDRESS CITY STATE ZIP CODE

HOME PHONE NUMBER PARENT/LEGAL GUARDIAN EMAIL ADDRESS

CURRENT SCHOOL

Apply online at www.mypbchoiceapp.comControlled Open Enrollment Application

THE SCHOOL DISTRICT OF PALM BEACH COUNTY DEPARTMENT OF CHOICE AND CAREER OPTIONS

School Board Policy 5.018, Controlled Open Enrollment, permits parents to enroll their child in a school other than the one to which they have been assigned. Applications for schools on the approved list must be received by the published deadline dates. The deadline dates will be posted on https://www.palmbeachschools.org/choiceprograms/controlled-open-enrollment/. For updated information regarding Controlled Open Enrollment in Palm Beach County and to view the list of schools available, visit https://www.palmbeachschools.org/choiceprograms/controlled-open-enrollment. Hard copy applications must be submitted by the published deadline date and mailed or hand delivered to the Department of Choice and Career Options, 3308 Forest Hill Boulevard, C-124, West Palm Beach, FL 33406-5869. Faxed applications will not be accepted.

MI LAST NAME

CURRENT COUNTY

CELL PHONE NUMBERPARENT/LEGAL GUARDIAN

Section A: Student Information (A separate application is required for each child)

Section B: Preferences (Documentation must be submitted if you select 'Yes' to any of the criteria below)

1. Is the parent or legal guardian active duty military personnel whose move resulted from military orders?(Copy of DD214 and military dependent verification must be submitted with application)

2. Has the student recently been relocated due to a foster care placement in a different home?(Copy of most recent court order or documentation must be submitted with application)

3. Has the student moved as a result of a court-ordered change in custody due to separation or divorce, or serious illness or death of a custodial parent?

(Copy of court order and/or proof of move must be submitted with application)

4. Are both the parent/legal guardian and student full time residents of Palm Beach County?(Proof of residency is required if child is not currently a PBCSD student)

5. List the name(s) and grade of any sibling* who is currently attending and will be attending the same school to which the applicant is applying for on this application. *Siblings are defined as brother, sister, half-brother, half-sister, stepbrother, or stepsister, living in the same household.

Sibling's Name Sibling's Current School Sibling's Current Grade

Yes No

Yes No

Yes No

Yes No

Page 2 of 2ORIGINAL - Choice and Career OptionsPBSD 2580 (Rev. 4/10/2018)

FOR OFFICE USE ONLY

6. List name(s) and grades of sibling(s)* applying to the same school as the applicant. (A separate application for each child must be submitted). *Siblings are defined as brother, sister, half-brother, half-sister, stepbrother, or stepsister, living in the same household.

Sibling's Name School Sibling is Applying To Sibling's Current Grade

GRADE APPLYING FORLAST NAMESTUDENT FIRST NAMEControlled Open Enrollment Application

Section C: School ChoicesThe list of schools available will be posted on the Department of Choice and Career Options website, at: https://www.palmbeachschools.org/choiceprograms/controlled-open-enrollment. Requests for schools that are not on the approved list will not be processed. Below list the name of the available Palm Beach County School being requested, ranked in order of preference. If requesting consideration for more than three schools, please list the additional schools in order of preference, on a separate sheet of paper and submit with application.

1.

2.

3.

Check here if attaching a separate sheet of paper to include additional schools in order of preference. Ensure student's names are on all attachments in addition to this application.

Section D: Acknowledgement

Date

DatePrint Name of Parent/GuardianSignature of Parent/Guardian

Print Name of Parent/GuardianSignature of Parent/Guardian

My signature below verifies that I declare that I have read this application and the information stated in this application is true and correct. I understand that I have the opportunity to ask questions and receive information regarding the controlled open enrollment policy.

I understand that: • transportation is the responsibility of the parent or guardian. • falsifying or omitting information requested may result in revocation of school assignment. • approval of this school assignment does not guarantee athletic eligibility. • the complete policy and procedure for Controlled Open Enrollment, can be found at https://www.palmbeachschools.org/

choiceprograms/controlled-open-enrollment.

DATEASSIGNED RANK SCHOOL YEAR PROCESSED BY

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