Student Services

Holly Shaffer, Director


Request for Release of Attendance


Please be sure to fill in all blanks and check all appropriate boxes on this form. You may print this form out and complete it by hand, or you can type directly onto the form on your computer.


Once the form is completed, please print out the form, and sign and date it.


You will need to bring this form with you to the Student Services Department, for district signature. We are located at:

Clover Park School District
Student Services Department, Room 5
10903 Gravelly Lake Drive SW
Lakewood, WA 98499
Tel: (253) 583-5154, Fax: (253) 583-5158
Hours: Monday-Friday, 7:30 am to 4:30 pm,
Closed 12:30 pm to 1:30 pm for lunch


You may also fax this form to us. Our fax number is (253) 583-5158. Please be sure to include your fax number, so we can fax the final signed version back to you.


We can only accept an emailed form with a signature attached. You may scan this form after signing it, and email it to:

If you have any questions, please contact Terese High, Director’s Secretary, at (253) 583-5154, or

Request for Release of Attendance

10903 Gravelly Lake Dr SW • Lakewood WA 98499-1341
(253) 583-5154

WAC 392-137-135, WAC 392-137-140; and
Clover Park School District 3131 Release of Resident Students

Separate form must be completed for each student requesting release of attendance.

This release request is for the school year. school year.


Check one box only:

New applicant (This is a first time request)

Renewal applicant (Student attended a school outside of Clover Park School District last year)

Reason for Request (Please give a detailed explanation for the request)

Would you consider returning to Clover Park School District in the future?

Student Name
(please print)
Last First Middle Date of Birth (mo/day/year) Gender
Male Female
Home Address City State Zip Code Home or Cell Telephone #
Parent/Guardian Name Parent Work Telephone #
Requested School Name Requested School District Resident School in Clover Park School District

Is the student currently being served by the following? (Check next to those that apply)

ELL LAP Special Education Title 1 Highly Capable Program

I have read and understand that approval of this transfer request is based on the following:

  • The term shall be for the current school year only.
  • Special education students must get a release addendum, approved or denied by the director of special education.
  • Parent/guardian is responsible for providing transportation for the student.
  • The information provided on this application is current and accurate. Falsification or incomplete information on this document may be cause for rescinding the request.

Signature of parent/guardian Date

For Office Use Only

Health Financial Educational Child Care Safety Parent’s Work Other
Special Program Already Attending; Moved Different Learning Environment
Denied Administrator Signature Date

Distribution: Original - Student Services copy - District Requested copy - Parent

This form is used to transfer out of the Clover Park School District

Requests for release from Clover Park School District are considered for the following reasons:

  1. Financial, educational, health or safety condition.
  2. Accessibility to work or child care.
  3. Hardship or detrimental conditions.

Separate forms must be completed for each student requesting a release of attendance.

  1. Complete the top portion of the form. Sign and date the form and mail or take the completed form to the Student Services Office, Room 5, Student Services Center, 10903 Gravelly Lake Drive SW, Lakewood, WA 98499.
  2. The request will be reviewed by the student services administrator, approved or denied, and returned to you.

The district shall provide equal employment opportunity and treatment for all applicants and employees in recruitment, hiring, retention, assignment, transfer, promotion, and training. Such equal employment opportunity shall be provided without discrimination with respect to race, creed, religion, color, national origin, age, sex, sexual orientation including gender expression or identity, marital status, veteran status or physical, sensory or mental disabilities, except insofar as such factors are bona fide occupational qualifications, or the use of a trained guide dog or service animal by a person with a disability.