Student Name
*
First Name
Last Name
Student STN
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Attendance
*
In Person
Phone
Meeting Date & TIme
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
REASON OPT-OUT MEETING IS INITIATED
Reason
*
Requested by parent/guardian (IC 20-32-4-7)
Student has received failing grades in three courses required for Core 40 (IC 20-32-4-8)
Student's GQE score is in the twenty-fifth percentile or lower (first attempt) (IC 20-32-4-9)
Parent/guardian does not attend meeting after two (2) written request to do so (IC 20-32-4-10)
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COMMUNICATION WITH PARENT/GUARDIAN PRIOR TO MEETING
Date of telephone call to parent/guardian prior to meeting
-
Month
-
Day
Year
Date
Result of telephone call
Spoke with parent/guardian
Left recorded message
Left message with other individual
No answer, no message left
First written request for opt-out meeting mailed
Yes
Mailing date of FIRST written request for opt-out meeting
*
/
Month
/
Day
Year
Date
Second written request for opt-out meeting mailed
Yes
Mailing date of SECOND written request for opt-out meeting
*
/
Month
/
Day
Year
Date
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PRESENT AT MEETING
Select the checkbox and type names
*
Rows
Present
First & Last Name
Counselor
Administrator
Spec Ed TOR
Student
Parent/Guardian
Other
DISCUSSED & REVIEWED AT MEETING
Items discussed/reviewed
*
Student's career and course plan
Student's grades/progress toward Core 40
Student's standardized test/graduation exam scores
Graduation Exam Scores
*
Rows
Score (#)
PASS
Did NOT Pass
Math (ISTEP 10)
English (ISTEP 10)
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The Student and Parent/Guardian have been read each of the following (CHECK EACH BOX)
*
1). Without a Core 40 Diploma, the student will not be admitted to most four-year colleges (but may still attend a four-year college via transfer from Ivy Tech, Vincennes University, etc)
2). Without a Core 40 Diploma, the student, as a general rule, will be less prepared for the workforce.
3). Without a Core 40 Diploma, the student will not be eligible to receive the maximum amount of financial aid for college from the state of Indiana.
POST-SECONDARY PLAN
Meeting Notes
DIPLOMA TRACK
The parent and student have determined that the student will achieve greater educational benefits by completing:
*
General Diploma
Core 40 Diploma
Box 3 Completion Requirements
*
PATHWAY TRACK
Selected Track
*
College
Military
Entrepreneurship
Work Force
Student Signature
*
Date of Student Signature
*
-
Month
-
Day
Year
Date
Parent/Guardian Signature
*
Date of Parent/Guardian Signature
*
-
Month
-
Day
Year
Date
Input at least one email address below to route the submitted form
Email Address #1
*
example@scsd2.k12.in.us
Email Address #2
example@scsd2.k12.in.us
Email Address #3
example@scsd2.k12.in.us
Submit
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