Paladin Academy 308 Northtown Drive Blaine MN 55434 Tel: 763-786-4799

SPECIAL EDUCATION STUDENT ACKNOWLEDGEMENT AND TUITION AGREEMENT

GENERAL INFORMATION: In accordance with Minnesota Statutes 127A.47, Subd. 5 as amended, a signed acknowledgement is required to confirm agreements for the education of students with disabilities receiving instruction. LEARNER IDENTIFICATION INFORMATION Learner Name (Last, First, Middle) State ID Number M e s s i n g e r ,S h e l b i e , 0 0 1 6 0 0 0 6 8 3 3 3 0 Date of Birth 4 / 2 0 / 1 9 9 5 Federal Setting 0 2 PARENT/CONTACT INFORMATION Name(s) M i c h e l l eJ o n e s Address/City/State/Zip Code 6 9 7M a i nS t r e e t/L i n oL a k e s /M N /5 5 0 1 4 Home Phone 7 6 3 4 3 9 2 5 0 3 Work Phone Other Name(s) Address/City/State/Zip Code / / / Relationship Home Phone P a r e n t Work Phone Relationship Gender M F State AID Category 0 8 :C h a r t e rS c h o o l E n r o l l m e n t Grade 1 1 Primary Disability Code and Description 0 8 :E m o t i o n a l / b e h a v i o rd i s o r d e r s School Last Attended 0 0 :L a s ty e a ri nap u b l i cs c h o o li nt h e r e p o r t i n gd i s t r i c t

SERVING DISTRICT INFORMATION District Name/number/type 4 1 0 4 :P a l a d i nA c a d e m y /4 1 0 4 /0 7 :C h a r t e r Address/City/State/Zip 3 0 8N o r t h t o w nD r i v e/ B l a i n e Contact R u t hB r a i e d y Program Name Comments: P r i m a r y-0 8 S e t t i n g-0 2 DISTRICT OF LEGAL RESIDENCE INFORMATION District Name/number/type F O R E S TL A K EP U B L I C /0 8 3 1 /0 1 :I n d e p e n d e n t Address/City/State/Zip Code 6 1 0 02 1 0 T HS T R E E T N/ F O R E S TL A K E/ M N Contact L I N D AM A D S E N Phone ( 6 5 1 ) 9 8 2 8 1 0 3 /5 5 0 2 5 Fax ( 6 5 1 ) 9 8 2 8 1 1 4 E-Mail l m a d s e n @ f o r e s t l a k e . k 1 2 . m n . u s County W a s h i n g t o n /M N/ 5 5 4 3 4 Fax 7 6 3 7 8 6 4 7 9 8 Regular Year Extended School Year Learning Year Entry Date 9 / 3 / 2 0 1 3 Exit Date 6 / 1 0 / 2 0 1 4

Phone 7 6 3 7 8 6 4 7 9 9

E-Mail r b r a i e d y @ p a l a d i n a c a d e m y . u s Location/Building P a l a d i nA c a d e m y

FISCAL RESPONSIBILITY ACKNOWLEDGEMENT The undersigned District of Legal residence hereby acknowledges fiscal responsibility for the above student's educational costs. It is understood that 0831: FOREST LAKE PUBLIC will be billed for special instruction and service costs provided for this student during the Fiscal Year 2 0 1 3-2 0 1 4 . 1 0 / 1 / 2 0 1 3 Date Date sent: 2 / 1 0 / 2 0 1 4

Signature - Superintendent/Responsible Authority

Please sign, date and return this form to Ruth Braiedy #4104: Paladin Academy