Written Notification of School Placement Decision

To be completed by a school official when it is determined that staying at the school of origin is not in the best
interest of a homeless student.

Date:_____________________________________________________________________________________________________________
Person completing form:__________________________________________________________________________________________
Title:______________________________________________________________________________________________________________
School:___________________________________________________________________________________________________________
In compliance with the McKinney-Vento Homeless Education Assistance Act and School Board Policy 6.503, the
following written notification is provided to:

Parent or Guardian:_______________________________________________________________________________________________
Student(s): _______________________________________________________________________________________________________
___________________________________________________________________________________________________________________

After reviewing your request to keep the student(s) listed above in the school of origin, the request is denied. This
determination was based upon:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
____________________________________________________________________________________________________________ ______
You have the right to appeal this decision by completing the second page of this notice. The appeal should be
returned to the school district’s homeless education liaison by ___________________________________________________.

Liaison’s name: __Michele Wilder_________________________________________________________________________________

Title: __Coordinator, KCS Homeless Education Program __________________________________________________________
Phone number: __(423) 378-2424_ Address: 400 Clinchfield St., Ste. 200, Kingsport, TN 37660___________________
The McKinney-Vento Coordinator with the Tennessee Department of Education:
__Justin Singleton______________________
__Contact Info: (615) 917-3750 or _Justin.Singleton@tn.gov__________________
In addition:
• The student(s) listed above has the right to remain in the school of choice pending
resolution of the dispute.
• You may provide written or verbal documentation to support your position. You
may use the form attached to this notification.
• You may seek the assistance of advocates or attorneys.

A copy of Tennessee’s dispute resolution process for students experiencing homelessness is attached.
The school system provided me with a copy of this notice. ___________________ (Initial)
 Written Notification of School Placement Decision

To be completed by the parent, guardian, caretaker, or unaccompanied youth when a dispute arises over
eligibility, enrollment, or school selection.
Please return the completed form to the local homeless education liaison by ____________________________________.

Date submitted: __________________________________________________________________________________________________

Student(s): _______________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Person completing form: _________________________________________________________________________________________
Relation to student(s): ____________________________________________________________________________________________
I may be contacted at (phone or e-mail):__________________________________________________________________________
I wish to appeal the school placement decision made by:__________________________________________________________
School(s): ________________________________________________________________________________________________________
I have been provided with:
□A written explanation of the school’s decision.
□Contact information for the local homeless education liaison.
□A copy of the State’s Placement Dispute Resolution Process for students experiencing homelessness.

Optional: You may include a written explanation to support your appeal in the space below—including which
rights you believe the school or school district has not honored. Documentation supporting your appeal may be
attached.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
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The school provided me with a copy of this form when submitted. _____________ (Initial)
If you choose to appeal the school system’s decision, a mandatory meeting will be scheduled within 5 business
days to discuss the issue. Your attendance at this meeting is required. Failure to attend this meeting will be noted
and potentially reported to the State.

PARENTS/GUARDIANS SHOULD NOT COMPLETE ANY INFORMATION BELOW THE DOTTED LINE.
……….………………………………………………………………………………………………………………………………………………………………….
This form was received by the homeless education liaison on ________________________________at _________a.m./p.m.

Liaison’s signature: _______________________________________________________________________________________________