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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a combination of factors that include poor achievement; attendance issues; poor attitude; lack of motivation; socially withdrawn; not connected with school; mental health issues; physical health issues; family dynamic issues, discipline or others.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