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Series 602.5.1P - Request for Consideration of Retention

Adopted: October 2006

To be completed by preassessment team:

Student's name _____________________________________  Birthdate ________________

(please print)      first                               last

Grade ___________  School ____________________________________________________

Names of parent(s)/guardian(s) _________________________________________________

Address ________________________________________ Phone (       )__________________

1.  Reason(s) why retention is being considered: 






2.  What alternatives/interventions have been tried to meet the student's needs?






3.  Standardized test data:





4.  Other test data or pertinent information (Light’s Retention Scale):








Signatures of Preassessment Team Members                          Title

Please check one:

   ❏ Refer to Child Study

   ❏ Complete 602.5.1.2P, Summary of Decision not to Proceed with Retention Assessment

   ❏ Complete 602.5.1.3P, Permission for Retention Assessment


Date of pre-referral meeting       Signature of Principal