Special Education Exit Form

Special Education Exit Form

Please complete this form at the time of a student's withdrawal from school, termination of special education services, revocation of consent, or other reason for exiting special education services.
Your Name
Student's Full Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
STN Number
Corporation Student is Withdrawing From
School Student is Withdrawing From
Grade
Exit Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Name(s)
Phone Number
Address
Reason for exit from special educaNametion
If the student is moving to a different school, what is the name and location of the school the student is moving to?
If the student is exiting to be homeschooled, was a special education service plan offer accepted or rejected by the parent/guardian?

Other
Special Education Service Plan Offer Form
If applicable, attach signed Special Education Service Plan Offer Form. This is only for students who have been withdrawn to home school

Cancelof
Your Name
Your Email
example@example.com
Should be Empty: