2017-2018 Community Residential Center Funds Roster/Withdrawal Form CRCF-2

2017-2018 Community Residential Center Funds Roster/Withdrawal Form CRCF-2 Roster must be signed and mailed; postmark must be within sixty (60) calendar days of enrollment in the CRC. Last day for additional Roster submission: May 15, 2017.

Local Education Agency: LEA #: Region Name: Select From Drop Down Date: Community Residential Center: **ESY services for Summer 2017 must be documented in the IEP; attach a copy of the DEC4 page noting the child’s ESY eligibility.

Child’s Child’s Last Name Child’s First Name Date of E G Disability Date of **ESY t e h n Based Upon CRCF-1 Withdrawals NC Student Birth n Enrollment for Enrollment d i e

c Information r

ID i Current School Dates t (PowerSchool #) y Year Date Code* (if applicable) Month/ Year

W-9 (provide description here) Check if newly enrolled child is replacing a withdrawn child 

______Signature of Exceptional Children Program Director Date

DPI Use Only Postmarked Date Date Reviewed Reviewed by MOF

Date Entered Entered by FFM# Notes: