Teacher Of Record Change Request Form For High School Teachers Only

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South Bend Community School Corporation
Special Education Services
 
Teacher of Record Change Request Form
For High School Teachers Only
Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________
Date of Birth: ___________________________ Grade: ___________
School: __________________________
Address: ____________________________________________________________________________________
Disability Area(s):
Primary: _________________________________________________________________
Secondary: ______________________________________________________________
Current Teacher of Record:______________________________________________________________________
New Teacher of Record: _______________________________________________________________________
Reason for Change:
Date: ________________________________
Signed: ______________________________________________
Please fax the completed request to Special Education Services (574.283.8105)

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