Summary Of The Student’s Academic Achievement And Functional Performance (26A)
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  Student name ,   Date of Birth   Summary Date Summary Date Summary Date
 
  Reason for Exit (check the one that applies):  
 

 
  Strengths/Interests/Learning Preferences: Strengths/Interests/Learning Preferences: Strengths/Interests/Learning Preferences:  
 
 
  Pre-Academic / Academic / Functional Skills Pre-Academic / Academic / Functional Skills Pre-Academic / Academic / Functional Skills  (Note results of any general State or district-wide assessments):  
 
 
  Cognitive Abilities: Cognitive Abilities: Cognitive Abilities:  
 
 
  Communication Skills: Communication Skills: Communication Skills:  
 
 
  Motor Skills (Fine/Gross): Motor Skills (Fine/Gross): Motor Skills (Fine/Gross):  
 
 
  Health: Health: Health:  
 
 
  Social/Emotional/Behavioral: Social/Emotional/Behavioral: Social/Emotional/Behavioral:  
 
 
  Self Help/Adaptive: Self Help/Adaptive: Self Help/Adaptive:  
 
 
  Student's Post Secondary Goal(s). Student indicates that education, employment, and/or living are:
1. 1. 1.
 
2. 2. 2.
 
3. 3. 3.
 
  Comments: Comments: Comments:
 
 

 
  Agency Linkages (check agencies known to be working with the individual or could be a resource to the individual)
 
Agency Contact Person and phone number, if known
  Regional Center
 
  California Children's Services (CCS)
 
  Dept. of Health and Human Services
 
  Mental Health Services
 
  Employment Development Department
 
  California Department of Rehabilitation
 
  Comm. College/University Disabled Student Services
 
  Other: 
 

 
  Other Recommendations: Other Recommendations: Other Recommendations:  
 
 

 
  NOTE: The state forms committee removed the following items (7.2013), and they no longer print:
 
  Pre-Vocational/Vocational: Pre-Vocational/Vocational: Pre-Vocational/Vocational:
 
  Dept. of Social Services (DSS)
 
  Probation