Student Add/Drop/Change Form

1.	Reason for Change:*
	--Please Select--Add to PowerIEPAdd to Class ListMoved into DistrictMoved out of DistrictDropped Out (Age 17+)GraduateHomebound/Hospital TutoringHome School by ParentWithdrawn by Parent/GuardianOther

2.	Reason for Change or Where did they move?* Note if moved out of Henry-Starks Serving Districts

3.	Add Date: First Day Attended (Match SIS) CURRENT YEAR
	mm/dd/yyyy

4.	Drop Date: Last Day Attended (Match SIS) LAST or CURRENT YEAR
	mm/dd/yyyy

5.	Students Name: (Match SIS)* Double Check Legal Name Spelling is Correct (no nicknames)
	First:   Middle:   Last:

6.	Gender:
	--None--FemaleMale

7.	Date of Birth:*
	mm/dd/yyyy

8.	SIS ID #

9.	(RIN) Medicaid #

10.	Student Resident District:*

11.	Student Home School:*

12.	Student Serving District:*

13.	Student Serving School:*

14.	Grade:*
	--Please Select--NoneECEPre-K AMPre-K PMK1st2nd3rd4th5th6th7th8th9th10th11th12th12+Graduate

15.	School Year:*
	--Please Select--22-2321-22

16.	Case Manager/Teacher/Clinician Name:* Special Education Only

17.	Primary Eligibility:*
	--Please Select--Intellectual Disability (IntD)Orthopedic Impairment (PI)Specific Learning Disability (SLD)Visual Impairment (VI)Hearing Impairment (HI)Deafness (D)Deaf-Blindness (D-B)Speech/Language Impairment (S/L)Emotional Disability (ED)Other Health Impairment (OHI)Multiple Disabilities (MD)Developmental Delay (DD)Autism (AUT)Traumatic Brain Injury (TBI)To be Determined-Initial Evaluation

18.	Secondary Eligibility: If Applicable
	--None--Intellectual Disability (IntD)Orthopedic Impairment (PI)Specific Learning Disability (SLD)Visual Impairment (VI)Hearing Impairment (HI)Deafness (D)Deaf-Blindness (D-B)Speech/Language Impairment (S/L)Emotional Disability (ED)Other Health Impairment (OHI)Multiple Disabilities (MD)Developmental Delay (DD)Autism (AUT)Traumatic Brain Injury (TBI)

19.	Parent/Guardian Name(s)* First and Last Names

20.	Parent/Guardian Contact Info:
	Address   City, State, Zip   Home Phone   Cell Phone   Work Phone   E-Mail

21.	Foster Placement:
	--None--YesNo