Withdrawal Information Sheet printable pdf download

Withdrawal Information Sheet

South Bend Community School Corporation

Special Education Department

215 S. St. Joseph St, South Bend, IN 46601

Ph: 574.283.8130 Fax: 574.283.8105

Withdrawal Information Sheet

Student:______________________________________________ Date Of Birth: __________________

SBCSC ID#: _____________STN#:___________________School: _____________________________

Teacher Of Record: ___________________________________________________________________

Area Of Exceptionality: ________________________________________________________________

Date WD: _______________________________Attendance Office Notified:______________________

(Date)

(Students must be withdrawn from the AS400 in order to be withdrawn from CODA)

Reason For Withdrawal (Please check one):

_____ Case Conference committee has determined student is no longer eligible for special

education services

_____ Dropped out

_____ No show

Last day of attendance: ______________

_____ Transferred to another SBCSC school: _______________________________________

_____ Moved out of SBCSC to: __________________________________________________

_____ Other: _________________________________________________________________

Please send this notice to the Special Education Department

For students 14 years and older who have withdrawn from the SBCSC, please attach the

Anticipated Services form as required by State regulations.

Copy to: parent, cum, TOR and original to Special Ed Dept.

8/5/10

Withdrawal Information Sheet