GCSEC Student Drop Form

Student Name *
Serving School *
Resident District *
Program/Service Dismissed from *
Teacher/Therapist Name *
Reason for Exit: *
Example: Moved, Not Eligible, Not Eligible, Other (please explain)
Exit Date *

Month Day Year
(last day attended or serviced)
Notes
This should be completed for each student that drops or is dismissed from your program/class to ensure accurate state reporting. If you have questions please let Phoebe know. Thanks!
Should be Empty: