Oakland Unified School District
OFFICE OF CHARTER SCHOOLS
Pursuant to the statute outlined below, please submit form within 30 days of the Exit of any student
who does not otherwise COMPLETE the school's program (i.e. graduate). Complete a Student Exit Form
in September for ALL students who do not return from the prior year.
PLEASE DO NOT submit Student Exit Form for either of the following:
1. Any student who does not attend at least one day of instruction.
2. Any student who has graduated or is promoted from the last grade level served
STUDENT EXIT FORM
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Charter School Name
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Today's Date
Student Information
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Student Last Name
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Student First Name
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Birth date
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Grade Level
K
1
2
3
4
5
6
7
8
9
10
11
12
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Gender
Male
Female
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English Language
Learner
Yes
No
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Special Education/
IEP
Yes
No
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CSIS Number
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First Day of Attendance
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Last Day of Attendance
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Ethnicity
Native American
Hispanic/Latino
African American
Asian
Filipino
White
Pacific Islander
Multiple Ethnicity
Parent/Guardian Information
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Parent/Guardian Name
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Relationship
*
Phone Number
Reason for Exit
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SELECT REASON FOR EXIT HERE AND COMPLETE APPROPRIATE SECTION BELOW
Voluntary
Expulsion
Voluntary
Report Reason Given
Dissatisfied
Avoid Retention
Too Far
Social Conflicts
Too Rigorous
Moved - Changed Address
Moved - Within District
Summer Exit/ Reason Unknown
Expulsion
Cause for Expulsion
Behavior/Discipline
Attendance
Pursuant to:
Education Code Violation
School-Specific Policy Violation
Upload Copy of Expulsion Letter
(REQUIRED)
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Certification Statement
By checking this box I am certifying that I have provided all requested information regarding the reason for this student's exit.
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Preparer's Name
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Preparer's Email
OFFICE USE ONLY
Mark if form submitted through SAO
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Indicates Response Required
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Effective January 1, 2006: 47605(d)(3) If a pupil is expelled or leaves the charter school without graduating or completing the school year
for any reason, the charter school shall notify the superintendent of the school district of the pupil’s last known address within 30 days, and shall,
upon request, provide that school district with a copy of the cumulative record of the pupil, including a transcript of grades or report card, and
health information.