Date: ________

Parents: _______

Student: _______ Grade: ______

Teacher: _______

It is the recommendation of the principal and teacher that the above student be retained in his/her current grade. The following data has been used to make this recommendation:

     1. ______________________________________________________

     2. ______________________________________________________

     3. ______________________________________________________

     4. ______________________________________________________

Assessment/Test Scores: Reading __ Math ____

__ Agree

__ Disagree Reason(s): _______



I (We) have been informed that my(our) child is behind his/her current grade level and that the school feels that my(our) child needs to be retained in _ grade. I(We) have also been informed that if my(our) child does not reach grade level by the time he/she is in high school, it may be difficult to meet high school graduation requirements. I am fully aware that this is a possibility, however, I still do not want my child to be retained.

______ __ Parent Signature Date

______ __ Parent Signature Date