Series 602.5.1P - Request for Consideration of Retention
Adopted: October 2006
Revised:
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
Procedures/602.5.1P/10-16-06