EXIT FORM
Colorado Department of Education (CDE) and the Colorado Instructional Materials Center (CIMC)

The intent of this form is to assist in the tracking of students in Colorado as a change of placement occurs.  
As part of the collaborative statewide registration process between the Colorado Department of Education (CDE) and the Colorado Instructional Materials Center (CIMC), 
this Exit Form should be filled out completely when a student who is blind or visually impaired withdraws from a Colorado school district, 
and returned to the CIMC as close to the date of withdrawal as possible.  
Thank you for your assistance in tracking students with visual impairments in Colorado.

Student's last name:
Student's first name:                                                                                      
SASID # (10 DIGIT):          
Date of birth: 
                                                                     
School district/administrative unit (AU) the student is leaving:
	
Date withdrawn from school district/AU:

Reason student withdrew: There are 6 choices below. Place the letter x before the underscore for the choice you are selecting
_moved in state
_moved out of state
_graduated
_parental choice
_unknown
_other
        

If the student is moving to another school district in state, enter the name of the new district here:
If the student is moving out of state, enter the state here (so we can avoid duplicate registrations on the federal quota census), if you know the state:

Braillewriter (with blue barcode): Is a brailler checked out to this student, yes or no?
If yes, has it been returned to CIMC, yes or no?

Additional information: please enter here: 


Name of person completing this form:
Date:
Phone number:
Email:


    
Please email, mail, scan, or fax this form to: 

Colorado Instructional Materials Center
1015 East High Street
Colorado Springs, CO 80903
Email: cimcregistrations@csdb.org
FAX: 719.578.2239


Revised.10.15.2020