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Items denoted with a red asterisk
*
are required.
*
Student NCWISE Number:
*
Student Name:
*
Case Manager Name:
*
Exit Date:
Exit Reason:
Moved Out of County
Parent Consent Revoked
Student Request
Enrolled in Private School
Withdrawn to be Homeschooled
Enrolled at College
Dropped Out of School
Aged Out of the Program
Graduated with Diploma
Graduated with Certificate
Deceased
*
Forms Completed and Closed in CECAS
Yes
No - Do not submit this until all required forms are completed and closed in CECAS
*
Interim or Exit COSF Completed and Verified in CECAS (PK Students Only)
NA
Yes
No - Do not submit this until COSF (interim or exit) is completed and verified in CECAS
*
Medicaid Billing Completed for Related Service/s:
Yes
No
NA