Student's name _____________________________________ Date ____________________
Grade ___________ School ____________________________________________________
Signatures of people in attendance:
Signatures of Preassessment Team Members Title
The team decision process has been completed in accordance with Administrative Regulation 602.5AR, Retention of Students in Kindergarten through Grade Eight. The above-named student is:
_____ not approved for retention.
_____ approved for retention in grade _____.
Signature of Principal Date
Parent or Guardian: Please sign below to indicate that you are aware of the decision that has been made.
Signature of Parent or Guardian Date
• Copy student's cumulative folder
• Copy director of elementary or secondary education
• If approved, copy to Student Information Supervisor