2017-2018 Out-Of-District Withdrawal Form OOD-3

Withdrawal form must be signed and mailed; postmark must be within thirty (30) calendar days of withdrawal.

Date: Local Education Agency: LEA#: District Name:

Child’s
NC Student ID
(PowerSchool #) / Child’s Last Name / Child’s First Name / Date of
Birth / Ethnicity / Gender / Disability
Based Upon CRCF-1 Information / Date of
Enrollment for Current School Year / Withdrawals / **ESY Enrollment Dates
(if applicable)
Month/ Year
Date / Code*
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1 - Transferred to LEAW2 - Transferred to private schoolW3 - Transferred to another CRCW4 - Moved out of school districtW5 - Moved out of stateW6 - Withdrawn from schoolW7 - Exited/no longer eligible for servicesW8 - DeceasedW9 - Describe below
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE

W-9 (provide description here)

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Signature of Exceptional Children Program Director/Coordinator Date

DPI Use OnlyPostmarked Date ______Processor ______MOF______Entered Date______FFM#______

NOTES:______

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