This agreement is prepared by the State Superintendent of Public Instruction, as required by Indiana Code 20-26-11- 3, to implement I.C. 20-26-11-2.5. Form III is to be used where the student's parents are divorced or separated but live in different public school corporations. Form III must be signed by the parent with physical custody or by the student if the student is eighteen (18) years of age and competent.

Student Information

Name: (last)_________________________________ (first)_______________________________(mi)___________ (street)________________________________(city)_________________________(state)______(zip code)_______ (date of birth) _________________

Last school corporation attended: __________________________________________________________________

School corporation elected: _______________________________________________________________________

Parent Information

Mother:

Name: (last) ________________________________(first)_________________________________(mi)__________ (street)____________________________________(city________________________(state)_____(zip code)______ (telephone) __________________________________(email)____________________________________________

Father:

Name: (last) ________________________________(first)_________________________________(mi)__________ (street)____________________________________(city________________________(state)_____(zip code)______ (telephone) _________________________________ (email) ____________________________________________

Parent with whom the student will live:______________________________________________________________

In order to make an election under I.C. 20-26-11-2.5, the parent or student, if the student is eighteen (18) years of age, understand and agree:

• This form must be completed and presented not later than fourteen (14) days before the first student day of the school year to the school corporation where the election to attend has been made.
• In order to make this election, one or both of the student's parents must live in the school corporation where the election to attend has been made.
• The election to attend the school corporation is effective for one (1) school year.
• This form must be completed and presented to the school corporation or each subsequent school year.

Sworn and subscribed before me this _________ day of ____________________, 20_____.

_______________________________ resident of _____________ County. Expires: ___________

(notary public)