Withdrawal From Section 504 Form Page 2

WITHDRAWAL FROM SECTION 504

This form is used:

When a student totally withdraws from school or Section 504.

Provide documentation of specific changes to be made and the timing for those changes.

Directions:

1. Enter the student’s name, ID# and grade.

2. Enter the named of the school and program that the student is currently attending.

3. Enter the name of the Case Manager assigned to this student.

4. Check the box(es) that are pertinent to the action(s) that are proposed.

5. Enter the corresponding date for this action(s).

6. Enter the exit code (choices at the bottom of the page)

7. Gather and update student records

8. Check with classroom teacher and/or school secretary for general education forms to be

completed.

9. Send files to appropriate person/agency:

a. Student Withdrawals- send special education files to Special Services Office,

Attn. Kerry Desmarais

b. Working files are to be kept by the teacher and not sent to the Special Services

Office.

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