Services Discharge Form "*" indicates required fields Staff InformationStaff completing the form First Last Staff Role*AdvocateEarly Literacy CoachDirector/Manager/CoordinatorStudent InformationPlease select the FFC program*EDUCATEENRICHEMPOWERStudent Name* First Last Year Services Started Month Services Started*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberReason why services are being terminated* Declined Services Moved (Outside Orange County - OC Grants) Moved (Outside the tri-county) Runaway Incarcerated No contact in 90 days Termination Successfully Graduated from the Program No other services were needed Student does not qualify for services Grant Transfer Other Please select the current grant that the student is part of*1118511197112031122911231112361122711251112431126011265112681174411792118021177111779117841178611750Please select the New Grant that the student is being transferred to*1118511197112031122911231112361122711251112431126011265112681174411792118021177111779117841178611750If other, please specify*Input provided from* Caregiver Case manager Tutoring agency Client Other If other, please specify* Date Services Should End* MM slash DD slash YYYY Is the student enrolled on a Extracurricular Activity that the Foundation is paying for it? (ENRICH)* Yes No Enrich Coordinator has to be updated on this discharge so the Foundation stops paying for the activity.Discharge Summary*In a few words, please describe why this student is being dischargedElectronic SignatureBy my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.Electronic Signature Electronic Signature By checking this box you accept this electronic signature.
