CHANGE OF ENROLLMENT STATUS FORM
Clinton County Joint Services
STN
*
Grade
*
Name
*
DOB
*
Corporation
*
Educating School
*
EXIT DATE IN STUDENT INFO SYSTEM
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PLEASE CHECK AND COMPLETE
• Transfer within Joint Services to
• Transfer within Indiana
• Transfer out of state
• Withdrawn to Homeschool (no Service Plan)
Graduated with Diploma
Certificate of Completion
• Dismissed from special education services
•Other (please specify)
Date Completed
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
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