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AWSSC Enrollment/Withdrawal Form
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Email
*
Your email
STN:
*
Your answer
DOB:
*
MM
/
DD
/
YYYY
Grade:
*
Choose
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Student Name:
*
Your answer
Parent/Guardian:
*
Your answer
Address:
*
Your answer
City:
*
Your answer
ZIP:
*
Your answer
Phone:
*
Your answer
Primary Eligibility:
*
Choose
Autism Spectrum Disorder
Blind or Low Vision
Deaf/Hearing Impairment
Developmental Delay
Emotional Disability
Intellectual Disability
Language Impairment
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Speech Impairment
Traumatic Brain Injury
Secondary Eligibility:
*
Choose
None
Autism Spectrum Disorder
Blind or Low Vision
Deaf/Hearing Impairment
Developmental Delay
Emotional Disability
Intellectual Disability
Language Impairment
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Speech Impairment
Traumatic Brain Injury
Enrollment Information
Transfer within AWSSC to
Choose
Adams Central Community Schools
Bluffton-Harrison MSD
North Adams Community Schools
Norwell Community Schools
South Adams Schools
Southern Wells Community Schools
Transfer within AWSSC from:
Choose
Adams Central Community Schools
Bluffton-Harrison MSD
North Adams Community Schools
Norwell Community Schools
South Adams Schools
Southern Wells Community Schools
Additional Comments: Please list new teacher of record and previous teacher of record
Your answer
Initial Eligibility Case Conference Date
MM
/
DD
/
YYYY
Move-in from (School/Corporation/Date):
Your answer
Withdrawal Information
Date of transfer, graduation, move, etc.:
MM
/
DD
/
YYYY
Transfer within AWSSC to:
Choose
Adams Central Community Schools
Bluffton-Harrison MSD
North Adams Community Schools
Norwell Community Schools
South Adams Schools
Southern Wells Community Schools
Transfer within AWSSC from:
Choose
Adams Central Community Schools
Bluffton-Harrison MSD
North Adams Community Schools
Norwell Community Schools
South Adams Schools
Southern Wells Community Schools
Additional Comments: Please list new teacher of record and previous teacher of record
Your answer
Graduation with Diploma
Certificate of completion
Student is dismissed from speech/language services only.
Student no longer eligible for services
Student dropped out.
Parent/Student revoked permission for services
Student moved to a different Indiana corporation
Student moved out of state.
Student enrolled in a non-public school (or home schooled); rejected a service plan
Student enrolled in a non-public school (or home schooled)
Student is court-ordered to a facility and does not exercise right to attend school in that district.
Student is incarcerated in an adult Department of Corrections facility and has no access to secondary education.
Student is deceased.
Preschool student not attending school and not eligible for service plan.
Student withdrew due to religious reasons. (i.e. Amish)
Completed by:
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