Withdrawal App
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Student Name
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First Name
Middle Name
Last Name
STN
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Which corp is this child withdrawing from?
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Please Select
Greater Jasper
Southwest Dubois
Northeast DUbois
Southeast Dubois
North Spencer
South Spencer
Cannelton
Tell City
Perry Central
Pike County
Did the student withdraw to Homeschool?
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YES
NO
Was a Service Plan offered? (If you have questions regarding this, please contact Tammy Hurm)
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YES
NO
Please Explain:
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Did the parent/guardian accept the Service Plan?
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YES
NO
OFFICE USE ONLY:
DO NOT Remove from IIEP/SIS. SP has been created.
Which School or Program are they enrolling in?
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Please Select
Non-accredited Program
Accredited Program IN Indiana
Indiana Connections Academy
Hoosier Academics
Unknown
Please Specify:
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Withdrawal Code 16
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16 ~ MOVED OUT OF STATE, HOMESCHOOLED, PK NON-ATTENDER, RESIDENTIAL/CORRECTIONAL FACILITY (Code 7)
Withdrawal Code 17
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17~ MOVED OUT OF DISTRICT, KNOWN TO CONTINUE IN INDIANA SCHOOL DISTRICT
Which School or Program are they enrolling in?
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Please Select One of the Following:
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*1 ~ RETURNED TO REGULAR EDUCATION--NO IEP IN EFFECT (Code 1)
*11 ~ GRADUATED WITH DIPLOMA (Code 2)
*12 ~ GRADUATED WITH CERTIFICATE, FULFILLED IEP, RECEIVED GED (Code 3)
*13 ~ REACHED MAXIMUM AGE (Code 4)
*14 ~ DECEASED (Code 5)
*15 ~ DROPPED OUT (Code 6)
*16~ MOVED OUT OF STATE, HOMESCHOOLED, PK NON-ATTENDER, RESIDENTIAL/CORRECTIONAL FACILITY (Code 7)
*17 ~ MOVED OUT OF DISTRICT, KNOWN TO CONTINUE PROGRAM IN INDIANA
*99 ~ END OF PROGRAM
Please explain:
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Which School or Program are they enrolling in?
*
How was diploma earned?
Passing ECA
Waiver Process
Last Day of Attendance in your school corp? (If this is a summer withdrawal, please use the date predetermined by your school corporation after July 1st to be included in the current TR-Transition Report).
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Month
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Day
Year
Date Picker Icon
Exit Date from your School Corporation?
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Month
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Day
Year
Date Picker Icon
Graduation Date?
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-
Month
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Day
Year
Date Picker Icon
Date Student was Returned to Regular Education?
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-
Month
-
Day
Year
Date Picker Icon
Please enter your name.
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First Name
Last Name
Was this student Speech/Language Only?
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YES
NO
Do they need a 504 Plan for accommodation?
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YES
NO
Corporation 504 Coordinator
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First Name
Last Name
Date Contacted
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please enter your email address
*
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