Nonpublic School Change Request - Grade Reconfiguration or Name Change

Nonpublic School Change Request Form - Reconfiguration or Name Change
Instructions for Completing This Form:

Complete only the section that applies to the type of change you are requesting. Please do not complete multiple sections on the same form. This form must be submitted by April 1 of each year.

NOTE: To ensure proper review and processing, applicants must complete either Section C or Section D, as applicable to the reason for submitting this form. All remaining sections of the form are also required. Incomplete submissions may delay evaluation and approval.
Use this form to request a change for one of the following:
Section A - Primary Contact Information
Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Request

MonthDayYear
Date
Section B - Change Type
What type of change are you requesting?

Section C - Grade Reconfiguration

If you are requesting a grade reconfiguration, please complete Section C. Note: If you are requesting a grade reconfiguration and do not fill out this section in its entirety, evaluation and approval may be delayed.
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Grade Configuration
Requested Grade Configuration
Effective Date of Reconfiguration

MonthDayYear
Date

Section D - Name Change

If you are requesting a name change, complete Section D only. Note: If you are requesting a name change and do not fill out this section in its entirety, evaluation and approval may be delayed.
Current School Name
Revised School Name
Grade Levels Served
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Effective Date of Name Change

MonthDayYear
Date

Section E - Formation of a New LEA from Multiple Existing Schools

If you are requesting to create a new LEA, complete Section E only. Note: If you are requesting the formation of a new LEA and do not fill out this section in its entirety, evaluation and approval may be delayed.
Proposed LEA Name
Proposed Effective Date
Anticipated First Year of Operation
List All Schools Included in the Proposed New LEA

Section F - Supporting Documentation
Date of Board Approval

MonthDayYear
Date
Upload your school's dated and signed board minutes indicating the approval of requested changes.

Cancelof

Section G - Submission/Acknowledgement

Thank you for submitting your nonpublic school change request. The ND Department of Public Instruction will review your submission and contact you if any additional information is required. Please retain a copy of your responses for your records.
Signature

Clear
Should be Empty:

Nonpublic School Change Request Form - Reconfiguration or Name Change