REQUEST FOR HAG ASSIGNMENT by ZoyI2bj

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									          2013-2014 REQUEST FOR HAG RE-ASSIGNMENT
Please print using black or blue ink to complete this form.

Student Last Name:                                                             Student ID #:

Student First Name:                                                            Student Middle Initial:

Ethnicity: _________________________________________________________________________________

Parent or Guardian Name:

Home Street Address:

City:                                                         State:                    Zip:

Home phone:                                           Cell phone:

Mother email:                                                 Father email:

2012-2013 School Assignment:                          ___________ 2012-2013 Grade: ____________________


2013-2014 Request for HAG Assignment to:

                                      [ ] Brunson Elementary School;           Grade:

                                      [ ] Hanes Middle School;                 Grade:

                                      [ ] Remain in AG at our home school

Parent Signature:                                                      Date:


                    PLACEMENT DECISION MUST BE SUBMITTED BY JUNE 14, 2013

Note: Middle school students who request to receive HAG services at Hanes Middle School must also have a
magnet application on file. If you have not already submitted a magnet application, please send it along with
this form. Magnet applications can be found at
http://wsfcs.k12.nc.us/cms/lib/NC01001395/Centricity/Domain/35/2012%20Magnet%20App%20Middle.pdf.


Mail to:                                                      Fax to:
Paula Wilkins                                                 Paula Wilkins
AIG Program Specialist                                        336.661.4986
Winston-Salem / Forsyth County Schools
PO Box 2513                                                   Email to:
Winston-Salem, NC 27103                                       pbwilkins@wsfcs.k12.nc.us

								
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