UISD Withdrawal Procedural Manual - United Independent School ...

UNITED INDEPENDENT SCHOOL DISTRICTLeaver Verification FormInitiated by: Parent Student AdministratorCAMPUS NAME:Campus ID# 240903SCHOOL YEAR: 2012 - 2013DEMOGRAPHIC INFORMATION Sp. Ed Sec. 504 LEP MigrantStudent Name: Student ID: Grade Level:DOB: / / Social Security/PEIMS ID#:Current/Previous Address City Zip Code Phone #: Alternate #:The parent/guardian listed below has requested permission to withdraw the student identified.Parent/Guardian’s Name:_______________________________________________________________________________________________________This adult withdrawing the student is: ______Custodial parent ______Step-parent with custody ______Court appointed guardianThe student will be residing withRelationship to the student:New Address City Zip Code Phone #: Alternate #:Withdrawal InformationWithdrawal Date: / / Reason of Withdrawal:Student will be attending:School/ProgramAddress of school/program: City: State:___01 Graduated___03 Died*___16 Return to Home Country*___24 College, Pursue Degree*___60 Home Schooling*___66 Removed-Child Protective Services*___78 Expelled, Cannot return*___81 Enroll in TX Private School*___82 Enroll in School outside Texas*___83 Not Entitled to Enrollment*___85 Graduated outside TX, left again*___86 GED Outside TX*LEAVER CODE:___02 Pursue a Job___04 Join Military___08 Pregnancy___09 Married___10 Substance Abuse___14 Age___15 Homelessness___19 Failed TAKS Met Graduation Requirements___22 Enroll Alter, Program w/documentation___24 Enter College w/documentation___30 Enter Health Care Facility___31 Completed GED Certificate___33 Mid-Term Graduate___61 Incarcerated outside District___63 Graduated, returned left again___64 Completed GED certificate, returned left again___67 Transfer within District___72 Alternative Program by Court Order___80 Enroll in Other Texas Public School___84 Academic Performance___87 Enroll in University - High School Program.___88 Court Ordered GED- Not earned GED*___89 Incarcerated State Jail or Penitentiary*___90 Graduate from another State*___98 Other (unknown or not listed)*New PEIMS Leaver CodesAttach supporting documentation to this form along with copy of official TEMS (TYLER) withdrawal form and place it in StudentsPRC TAB 4Leaver Tracking Notes/Comments: (Administrator, Counselor, Registrar, Attendance Clerk, Attendance Officer, etc.)Date: Description: By:(*Requires All three (3) Signatures)*Administrator:*Registrar:(Date)(Date)*Attendance Officer:Parent/Student Signature:(Date)(Date)UISD Form 882-006Revised: July 2012Office of Admissions~Attendance~Dropout Recovery