School:

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Student Last, First

St. Thomas School: _______________

Grade ______

OFFICE / TITLE I USE ONLY

Change of Status Form DO NOT NEED THIS FORM when sending below copies of PARENT SIGNED letters to Central Office for:  Continuing Services (EOY / Beginning next SY)  Continuing Services from another District  Parent Refused Services (PRS)  Initial Services parent permission w/Initial Enrollment form

‘s Title I Student’s Full Name

status has changed (Circle One or BOTH if applicable)

due to: (Check One, Fill-in FULL Date, Sign and send to Deborah Sanborn) _____ Special Education (√ Here)

Date: ______________

DATE ONLY)

_____ Re-Enter Services (√ Here)

Date: ______________ (T__)

(DATE ONLY)

__ ___ Transferred School w/in (√ Here) District (DATE ONLY)

Date: ______________

_____ Monitor

Date: ______________

(√ Here)

(DATE ONLY)

_____ Dismissed (√ Here)

Date: ______________

(DATE ONLY)

______ Moved (√ Here)

Date: ______________

(DATE ONLY)

_____ Other: _______________ (√ Here)

Date: ______________

Tier 2/Tier 3 Changes / Attendance / Behavior / Parent pulled / etc.

x__________________________ Title Teacher’s Signature

** This DOES NOT go in Working file. Rev.: 10/23/2018 VI-A-3