<p>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.</p><p>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.</p><p>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</p><p> c Information r</p><p>ID i Current School Dates t (PowerSchool #) y Year Date Code* (if applicable) Month/ Year</p><p>W-9 (provide description here) Check if newly enrolled child is replacing a withdrawn child </p><p>______Signature of Exceptional Children Program Director Date</p><p>DPI Use Only Postmarked Date Date Reviewed Reviewed by MOF</p><p>Date Entered Entered by FFM# Notes:</p>