JGSC SPECIAL EDUCATION STUDENT EXIT FORM 
(DATA COLLECTION FOR THE CORP’S’ TR REPORT)

Student Name: _________________________________________________________

DOB: ________________________________
  
Date Special Education Services Ended (should match withdrawal date): ______________________________

STN: _____________________  Teacher of Record: _________________________________________________

School the student was attending upon withdrawal/dismissal: _______________________________________

Termination Reasons/Codes: (please check only one)

1.	  _____ Transferred to regular education (Dismissed from services or parent revoked special education services)

       	 11.        _____Earned high school diploma

12.      _____Received a Certificate of Completion this year and does not intend on returning to school the following year. 
                          
_____ Received a Certificate of Completion this year and will return to school the following year.

_____Previously received a Certificate  of Completion. (Year_____) and returned to school; but has now W/D.

        13.      _____Reached maximum age 22

        14.       ____Deceased

        15.       ____Dropout

        16.       Moved, known to be continuing in a general education ONLY (not in an INDIANA  public school)

                   	a. ______ Moved out of state             STATE NAME: _____________________________________________________________________________                                                                                                                                                                                
            
b. _____ Withdrawn to homeschool - NOTE:  This requires the Corporation of Legal Settlement  to  offer a service plan
                
                  	c. ____ Enrolled in non-public school (in your district)    NAME OF SCHOOL: ______________________________________    NOTE:  This requires the Corporation of Legal Settlement  to  offer a service plan                               
                                                                                                                                                          
            17.      ____ Moved, but continuing Special Education services under IDEA in an INDIANA PUBLIC 
                                   SCHOOL CORP/CHARTER SCHOOL NAME _____________________________________________________________________________

           18.      ____ Alternate Diploma

 Person completing form: ______________________________________________     Date: