ADD • CHANGE • DROP
Traverse Bay Area
Intermediate School District
NOTICE
1101 Red Drive
Traverse City, Michigan 49684
UIC NUMBER: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Date: _____/_____/________
Student Last Name: ______________________________ Student First Name: _______________________
Date of Birth: _____/_____/__________ Grade: _______ School: _________________________________
Special Ed Teacher: ______________________________ Program: _______________________________
Itinerant Provider: ________________________________ Itinerant Service: _________________________
Itinerant Provider: ________________________________ Itinerant Service: _________________________
Itinerant Provider: ________________________________ Itinerant Service: _________________________
This form is a notification of change for the above student, which does not require a new IEP.
ADD
Student
Student Address: _____________________________________/_______/______
(within Local School District)
Home Phone: _______________________ Cell Phone: ____________________
Start Date: _____/_____/__________ Previous School: ____________________
Previous Provider(s): ________________________________________________
Parent/Guardian:
__________________________________________________
Address
: ___________________________________/_______/_______
(if different)
CHANGE
Placement
Provider: _________________________________________________________
(within School Building)
New Provider: _____________________________________________________
DROP
Student
Drop Date: _______/_______/__________
Moved to:
________________________________________________________
DROP REASON
□
□
01 Graduated General Ed with diploma
11 Enlisted in US Military or Job Corps
□
□
02 Graduated General Ed with diploma &
12 Deceased
□
applied to College
13 Adjudicated
□
□
03 Graduated from Alternative Program
14 Enrolled in Home School
□
□
04 Graduated & applied to non-degree Granting
15 Enrolled non Public School
Institution
□
16 Unknown
□
05 Completed General Ed with an equivalency
□
17 Placed in Recovery or Rehabilitative Program
certificate
□
19 Expected to continue in same School District
□
06 Completed General Ed with other certificate
□
20 Received Certificate of Completion or finished
□
07 Dropped out of School
IEP requirements
□
08 Enrolled in another Public School District in
□
21 Reached maximum age
Michigan
□
30 Exited Early Childhood or Early On Program &
□
09 Moved out of State
not continuing in District
□
10 Expelled from School
□
Exited prior to beginning IEP
Completed by: ____________________________ Title: __________________ Date: __________________
Return to TBAISD Special Education IEP Office
IEP Help Line (231) 922-6244 / FAX Number (231) 922-6315
jk: 02/24/2015