I CERTIFY by Completing This Form That

/ Department of Public Instruction
DESIGNATION OF SCHOOL EXCLUSIVELY SERVING “AT-RISK” STUDENT POPULATIONS APPLICATION / RENEWAL
PI-9550-ASA-DSE (Rev. 01-15) / INSTRUCTIONS: Complete form, collect signatures, scan into PDF, and return via email to:

For questions regarding this application / renewal form contact:
The information collected on this form is used for state accountability purposes, to identify schools eligible for an Alternate Accountability determination. / Reporting Year
2014-15
GENERAL INFORMATION
School District Name / District Code
School Name / School Number
School Programs and Student Population Check the description(s) that most closely describes your school. Check all that apply.
Credit recovery Expulsion / behavior reassignment center
Dropout recovery Pregnant / parenting students
GED option # 2 Employment and training center
Detention center or county jail
Other Describe:
CERTIFICATION / SIGNATURES

I CERTIFY by completing this form that:

1.  the school listed above is designed to exclusively serve students who are at-risk of not graduating from high school as defined by s.118.153, Wis. Stats. and PI 25, Wis. Admin. Code; and

2.  the school confirms that there is an annual at-risk plan in place as required under s.118.153(2)(a), Wis. Stats., and PI 25.03, Wis. Admin. Code.

Students who are at-risk of not graduating from high school as defined by s.118.153, Wis. Stats. and PI 25, Wis. Admin. Code include:

Pupils in grades 5 to 12 who are at risk of not graduating from high school because they are dropouts, or are two or more of the following:

§  one or more years behind their age group in the number of high school credits attained,

§  two or more years behind their age group in basic skill levels,

§  habitual truants, as defined in s.118.16 (1)(a),

§  parents,

§  adjudicated delinquents,

§  8th grade pupils whose score in each subject area on the examination administered under s.118.30(1m)(am)1 was below the basic level,

§  8th grade pupils who failed the examination under s.118.30(1m)(am)2,

§  8th grade pupils who failed to be promoted to the 9th grade.

More information regarding statute and administrative code is available at: http://at-risk.dpi.wi.gov/.

I FURTHER CERTIFY that the information provided is complete and accurate to the best of my knowledge.

Name of District Administrator / Signature of District Administrator
Ø / Date Signed Mo./Day/Yr.
Name of School Principal / Signature of School Principal
Ø / Date Signed Mo./Day/Yr.