Student Graduation Team Form

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Alleghany County Public Schools

P.O. Drawer 140 100 Central Circle

Low Moor, Virginia 24457



STUDENT
GRADUATION TEAM

 

NAME:                                                                          


DATE:                                                 

 

DOB:                                                  SCHOOL:                                   GRADE:                   

 

PARENT/GUARDIAN:                                                                                                          

 

MAILING ADDRESS:                                                                                                             

 

CITY:                                                                           STATE:                    ZIP:                    

 

HOME PHONE:                                                WORK PHONE:                                           

 

 

ACTIONS TAKEN AT THE SCHOOL LEVEL: Please check all that apply.


           PHONE CONTACTS


           HOME VISIT


           LETTERS MAILED TO PARENT                             MENTOR

           PLAN OF IMPROVED ATTENDANCE                    CHRONIC HEALTH PLAN

           BEHAVIOR PLANS/INTERVENTIONS                    STUDENT RESOURCE

           CONFERENCE WITH PRINCIPAL                         ANALYSIS (RUBY PAYNE)

           SCHOOL BASED INTERVENTION TEAM REFERRAL


           ALTERNATIVE PLACEMENT


           CONFERENCE W/ GUIDANCE


           EVALUATION FOR SPED/504                               INDIVIDUAL SUCCESS PLAN

           REFERRED TO SOCIAL SERVICES                    ATTENDS ALT. ED.

           REFERRED FOR COUNSELING

           OTHER

                                                                                                                      

 

Special Education       yes      no                    504 plan          yes      no

 

Case Manager:                                                                                                              

Elementary School Attended:                                                                                             

 


The goal of the Student Graduation Team is for the referred student to graduate with his/her cohort class.  Referrals should be considered only after all school level efforts have been exhausted.  Criteria for referral should include a combination of factors that include poor achievement; attendance issues; poor attitude; lack of motivation; socially withdrawn; not connected with school; mental health issues; physical health issues; family dynamic issues, discipline or others.

 

Standing team members include the Director of Assessment and Student Success, Director of Instruction, Director of Special Education, Visiting Teacher/Attendance Officer, Mental Health Counselor, Alternative Education Teacher, High School School Counselor, Middle School School Counselor, Principal from Alleghany High School, Principal from Clifton Middle School, Elementary School Principals, and Nurse Coordinator.  Referring schools will include the Principal, teacher (s), school counselor and others with relevant knowledge.

 

RED FLAGS TO LOOK FOR:

Number of discipline referrals

                            
 Attendance:        

                       
no. of days absent,

           no. of tardies

           no. of checkouts

Is the student in danger of failing?                  Yes                  No

What subject(s) is
the student failing?

 

Has the student been retained?                      Yes                  No

What grade(s)?                                                                                           

 

PRINCIPAL’S COMMENTS: Please document what has been done at the school level. This section must be completed.                                                                                                                           

PRINCIPAL’S SIGNATURE                                                     DATE