Location Transfer Request Form

Form Facts
What: Use this form if your family plans to travel or relocate, or if a student is regularly working at a location other than the one to
which materials and equipment were shipped. Students must be in good standing to be eligible for a location transfer.
How: Families with a student who will work at a non-home location must submit this form to the school’s principal/director, who
will consider transfer approvals on a case-by-case basis and in accordance with applicable state regulations.
Where: Submit along with the document cover page to: Connections Academy Enrollment | Upload to Connexus® at
www.connexus.com | Mail: 10960 Grantchester Way 3rd Floor, Columbia, MD 21044 | Fax: 800-887-6590

Reason for Transfer

Please check the box next to the type of transfer you are requesting and provide your reason for this transfer request.
Travel or relocation outside of the school jurisdiction for longer than two (2) weeks. Example: Family travelling for a
disclosed period of time. (Note: Connections Academy desktop computers and monitors cannot be taken out of the state. In WYCA,
students with laptops are allowed to travel with them. Please see School Handbook for details on equipment usage, loss, or
damage.)
Student learning regularly occurs in an alternate location within the school jurisdiction. (Residence is not changing.)
Example: The student’s Learning Coach is a neighbor, and the student regularly works at the Learning Coach’s home.
Reason for Transfer:

Family Members
List the family members affected by this transfer and each member’s role in the household.

Name (Last, First, Middle)/Student Grade Level Role:

Example: Edison, Thomas Alva/Grade 10 Student Parent/Guardian Learning Coach
Student Parent/Guardian Learning Coach
Student Parent/Guardian Learning Coach
Student Parent/Guardian Learning Coach

Student Parent/Guardian Learning Coach

Alternate Address
Indicate the new location where the student will be working and to which the materials and/or equipment will be moved.
Street Address Apartment/Unit # County
City State ZIP Code
Home Phone Alternate Phone
Transfer Start Date Transfer End Date

Signature of Parent/Legal Guardian

The student’s parent/legal guardian must sign and date below for this form to be valid.
By signing below, I certify that the above information is true to the best of my knowledge.
Parent/Legal Guardian’s Name (Please print)
Parent/Legal Guardian’s Signature Please print and sign. Date

For Office Use Only

Date Reviewed Principal/Director’s Name
Principal/Director’s Signature

Approved Denied Notes:

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