Name of student__________________________________________________________
| Date of birth |
_______________________ |
Age____________ |
|
Grade |
_________________ |
| School |
______________________________ |
Teacher |
______________________________ |
| Petitioner |
_________________________________ |
Date of request |
__________________ |
I am requesting that the above named student be considered for admittance into the PEAK program. The reasons I am making this request are as follows:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Attach additional sheets as needed and return completed petition to:
Dr. Gloria Shamanoff Northwest Allen County Schools
13119 Coldwater Road
Fort Wayne, IN 46845