NEW YORK STATE EDUCATION DEPARTMENT



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| |NEW YORK STATE EDUCATION DEPARTMENT |

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| |DISTRICT CHANGES IN SCHOOL DESIGNATIONS (NEW SCHOOLS, MERGERS, SPLITS, CLOSURES, AND/OR CHANGES IN NAME, LOCATION AND/OR GRADE CONFIGURATION) |

If the district is making changes to more than one school, please provide a summary of the changes for ALL the schools in the district requesting a change. Please note any changes in demographic information, staffing and any specific changes in curriculum, resources, etc. Add rows as needed and/or attach an separate sheet with the required explanations. (For example, Building A will send all K-5 students to Building B. Building B will keep its 6-8 grade students and merge with another 6-8 building, Building C.) Please note in addition to the District Summary, you must complete a separate petition and corresponding addenda for each new school that will be created.

|District Name: |Contact Person ( only if different from Superintendent): |

|Superintendent: |Contact Phone: |

|Superintendent Email: |Contact E-mail: |

|School Name |BEDS Code |Current Year |Proposed for Next Year |Form(s) |

1. | |Grade Levels |# of Total Students |Grade Levels |# of Total Students |Proposed Changes

(i.e., new school, split, merge, change to grade/enrollment configuration, phase-out/closure, and/or change of name) |Request |Petition |A |B |C |D |School Impact | |ABC School |012345678900 |K-6 |360 |K-12 |580 |Split grade 6 and merged with DEF Junior/Senior High School |√ | |√ | | |√ | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

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