Enrollment / Exclusion Form
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1
2ENROLLMENT / EXCLUSION FORM
To Implement Sections 16-28-40 through 16-28-45, Code of Alabama, 1975
Follow instructions on the back of this form. Print or type all information.
I. APPLICANT*
Social Security No.:
Sex:
Driver's License No.:
Male/Female
Date of Birth:
Legal Name:
Last
First
Mi
MM/DD/YY
Address:
City
State
Zip
Street
11. ENROLLMENT* SCHOOL OR GED OR JOB TRAINING PROGRAM
Check one:
Name:
GED Program
(School or in GED or Job Training Program)
Job Training Program
Secondary School
Address:
Street
City
State
Zip
Telephone No.:
Signature:
Title:
Enter the actual date of compliance or noncompliance in the blank located to the left of the appropriate statement.
IN COMPLIANCE
NOT IN COMPLIANCE
The applicant:
The applicant:
Is not enrolled.
Is enrolled.
Date
Date
Withdrew due to circumstances beyond
Has accumulated more than 10 consecutive
Date
Date
his or her control.*
or 15 cumulative unexcused absences during
a single semester.
Has obtained a GED Certificate.
(Only for students enrolled in secondary school)
Date
The applicant was previously reported as
Is not making satisfactory progress.
Date
Date
being noncompliant. As of this date, the
(Only for GED students)
student has complied.
111. EXCLUSION
Enter the actual date in the blank located to the left of the appropriate statement.
The applicant:
Is a parent with the care and custody of a minor
Date
Physician/Health Department
or unborn child.
Street
Is the sole source of transportation for the parent(s).
Date
City
State
Zip
Phone
Physician's Signature
Enter the beginning date of employment.
Place of Employment
The applicant:
Street
Is gainfully and substantially employed.
Date
City
State
Zip
Phone
*Defined on the back of this form.
Revised 5/1/95
Employer's Signature
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