Student Add/Drop/Change Form

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For HSCSED students transferring in or out of district.

Reason for Change *

Reason for Selecting Other or Where did they Move?

(Note if moved out of HSCSED Serving Districts)

Add Date: First Day Attended (Match SIS-Current Year)

YYYY

Drop Date: Last Day Attended (Match SIS-Last or Current Year)

YYYY

Students Full Name: (Match SIS)-

Double Check Legal Name Spelling is Correct (no nicknames)

Gender

Male

Female

Clear selection

Race *

Date of Birth *

YYYY

SIS ID #

(RIN) Medicaid #

Resident District *

Home School *

Serving District *

Student Serving School *

Grade *

Case Manager/Teacher/Clinician Name *

Primary Eligibility *

Secondary Eligibility (if applicable)

Parent Guardian Name(s) First and Last *

Parent/Guardian Contact Info (Full Address & Phone)

Foster Placement

Yes

Clear selection

Submit

Clear form

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