Use this form for either Original Submission OR to Update an Existing Plan DATED: .

Student Name (Last, First, MI.):

School:

After School Site:

Date:

Go to: English - Math - Science - Social Studies - Behavioral - At-Home - Other
____________________

Academic Goals:

English ________________________________________________________

Goal:

Support Personnel:

Evaluation Date:

Work in Progress:

Goal Met: Yes - No

Report Card Grade:



Math _________________________________________________________

Goal:

Support Personnel:

Evaluation Date:

Work in Progress:

Goal Met: Yes - No

Report Card Grade:




Science ________________________________________________________

Goal:

Support Personnel:

Evaluation Date:

Work in Progress:

Goal Met: Yes - No

Report Card Grade:



Social Studies ___________________________________________________

Goal:

Support Personnel:

Evaluation Date:

Work in Progress:

Goal Met: Yes - No

Report Card Grade:



Social Goals:

Behavioral _____________________________________________________

Goal:

Support Personnel:

Evaluation Date:

Work in Progress:

Goal Met: Yes - No

Report Card Grade:



At-Home ______________________________________________________

Goal:

Support Personnel:

Evaluation Date:

Work in Progess:

Goal Met: Yes - No

Report Card Grade:



Other ___________________________________________________________

Briefly Describe Other:

Goal:

Support Personnel:

Evaluation Date:

Work in Progess:

Goal Met: Yes - No

Report Card Grade:



__________________


Validation (Name and E-mail):

Note: Your submission is EITHER Original Submission OR Update and Existing Plan - be sure of the correct selection at the top of this form.