Public School Change Request - Grade Reconfiguration or Name Change

Public 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.
Grade Reconfiguration - Go to Section C (REQUIRED)School Name Change - Go to Section D (REQUIRED)
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
Grade Reconfiguration - Go to Section C (REQUIRED)Name Change - Go to Section D (REQUIRED)

Section C - Grade Reconfiguration

If you are requesting a grade reconfiguration, please complete Section C only. 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 District Name
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
Example: PK-4, 5-8, 9-12
Effective School Year 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.
School District Name
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 - 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 F - Submission/Acknowledgement

Thank you for submitting your public 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.
Should be Empty:

Public School Change Request Form - Reconfiguration or Name Change