Suggested Form for Requesting School District Facilities for a Charter School Pursuant to Education Code Section 47614 and Title 5 of the California Code of Regulations, Sections 11969.1 through 11969.10.
This form is provided pursuant to Section 11969.9(c)(3) (Outside Source)of Title 5 of the California Code of Regulations. Charter schools are encouraged to review all applicable Education Code and regulation sections before completing this form. Charter schools should also consult with the school district from which they are requesting facilities to determine if this, or another form, is required.
| Charter School Name ___________________ | Charter Authorizing Entity ________________ |
| Contact Information: Name: _______________________________ |
Phone: _______________________________ |
| E-mail: _______________________________ | Address: _____________________________ |
| Has the charter been approved? | Yes | No |
| Is this a continuing or new school? | Continuing | New |
Actual or anticipated date of local charter approval: ___________________________________
District from which charter school is requesting facilities: _______________________________
| Date request submitted: _________________ | Anticipated date of occupancy: ______________ |
Please provide the following estimates of average daily attendance (a.d.a.) by grade level (consult the regulations for definitions of each term):
| Grade | Total a.d.a. | Total In-District a.d.a. | Total Classroom a.d.a. | Total In-District Classroom a.d.a. |
|---|---|---|---|---|
K |
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1 |
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2 |
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3 |
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4 |
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5 |
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6 |
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7 |
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8 |
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9 |
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10 |
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11 |
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12 |
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Total |
Please attach the following documents:
- For the in-district classroom a.d.a. identified above, please provide, by grade level, a list indicating the school in the district that the pupils are otherwise eligible to attend and the number of pupils from each school.
- A description of the methodology used for the a.d.a. estimates above.
- Documentation of the number of in-district students interested in attending the charter school, if relevant.
- A description of the general location in which the charter school wishes to locate.
- A description of the charter school’s educational program that is relevant to the assignment of facilities.
- A copy of the charter school’s instructional calendar.
