Date: _________________ High School: ________________________________________
Student’s Name: ________________________________________
Town Responsible for Student: ____________________________
Fill Out Relevant Portion
January Progress June Progress
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Please attach a copy of this semester’s rank card.
Concerns with the student:
Transferred to another high school Date: __________________________________
Moved to another town. Date: __________________________________
Has been absent for more than 10 school days. Dates of absence: _________________________
Has been removed for disciplinary reasons. Date: __________________________________
Referred to an alternative program.
Referred to Student Assistance Team.
Has been referred by staff or parent/guardian for consideration as a possible special needs student.
Other.
Summary of action to be taken in response to concerns:
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Adopted: July 8, 2002
*Please excuse any formatting errors.