Sec 25 Nov 2013 Kent/Ottawa Pupil Membership Services Kent Intermediate School District

Ottawa Area Intermediate School District

Directions: Scan this form and required documentation into one PDF document and place it in the appropriate ISD

SFTP and notify auditor by e-mail that it has been placed. Label document with pupil’s last name and the date of submission to ISD.

Submitting/Enrolling District: Date Submitted to Auditor:

District Code: Contact Name & Number for Info if Needed:

Enrolled Pupil’s Name: Last Name, First Name, MI / UIC / Date of Birth / Resident District / Resident District Code

Enter Information from MSDS Student History:

Name of District that Claimed Pupil in Fall Count / District Code / ISD Code / FTE Claimed in Fall
Name of District Pupil Exited – if Same District that Claimed Pupil in Fall Count (see above) Enter Same / District Code / ISD Code

Pupil’s Enrollment & Membership Information in New District

Building Attends / Grade / Date Enrolled / First Date of Attendance / GE FTE / SE FTE / SE Prgm Code / If Sec 53 or Sec 24, Indicate Below

Documentation: The following documents must be submitted with this request form. Place an X verifying that each is attached.

1. / Copy of parent/guardian/placing agency completed enrollment form with signatures and date.
2. / If non-resident pupil, submit authorizing enrollment document (i.e. SOC form, IEP, Resident Release, etc.). If resident enter NA.
3. / Screen-shot of student history in MSDS showing/documenting district that claimed pupil in fall membership count.
4. / Print-out of pupil attendance records verifying first day of attendance.
5. / If pupil is on a seat-time-waiver versus building attendance, submit documentation of first log-in.
6. / Pupil schedule that documents full-time or part-time enrollment status.
v  For ISD Auditor Use Only

This verifies documentation was reviewed, that discussion occurred with other district/ISD as applicable by Kent/Ottawa Pupil Membership Services Auditor, and that finalization occurred in the MSDS application.

Name/Signature Date