COURSE OF STUDY EVALUATION FOR FOSTER YOUTH
Per AB 216 Legislation [effective January 1, 2014]
Student [last, first, mi]:
Date of birth:
Grade:
Current school of attendance:
Current district of attendance:
Mandatory evaluation timeline:
Date of school entrance/transfer in date:____________
30 day deadline to notify student of eligibility: ___________
Date of this evaluation: __________________
Prior high school(s)s attended:
Grade: ___ School: ____________________________________
AB 216 eligibility criteria:
(all three boxes must be checked to be eligible)
COURSE
English
Grade: ___ School: ____________________________________
 Changed schools and/or districts in grades 11 or 12.
 Completed at least 2 years of high school
 Would not reasonably be able to complete the district’s
graduation requirements by the end of the 4th year of high
school.
AB 216 Transcript Evaluation
Each box = 1 semester of coursework (5 credits) 1 course = 1 full year of study (10 credits)
***ELECTIVE CREDITS DO NOT COUNT TOWARD GRADUATION REQUIREMENTS
English
English
English
English
English
English
World History
World History
U.S. History
U.S. History
Gov.
Econ.
Physical
Physical
Life
Life
Algebra I
Algebra I
Math
Math
PE
PE
PE
PE
F.A. or F.L.
F.A. or F.L.
3 courses
Social Studies
3 courses
Science
2 courses
Mathematics
2 courses
Physical
Education
2 courses
Fine Arts or
For. Lang
1 course
CAHSEE
Score of 350/better
Math
English
Passed
Failed score: ___________
Exempt from CAHSEE per AB X4 2
Passed
Failed score: ___________
Exempt from CAHSEE per AB X4 2
130 Total credit requirement per AB 216
- ____ Total credits earned
=____ Credits needed to meet AB 216 requirements for
graduation
___ Total credit requirement per district
- ____ Total credits earned
=____ Credits needed to meet district’s requirements for
graduation
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Name:
Birthdate:
/
/
Meeting Date:
/
/
AB 216 MEETING PARTICIPANTS
Please print names
Ed Rights Holder
Student
Admin/Designee
Counselor
Caregiver
Social Worker
other:___________
other:___________
other:___________
other:___________
AB 216 DETERMINATION
Check only one box.
The student is not eligible for AB 216.
The student is eligible for AB 216.
SAFEGUARDS & NOTIFICATIONS TO STUDENT AND EDUCATIONAL RIGHTS HOLDER
 The district is prohibited from requiring eligible student to graduate before the end of his/her fourth
year. [ed rights holder ___________ student_____________]
 Graduation under AB 216 does not entitle the student entrance into a 4 year university/college. The
youth is eligible to attend a community college and utilize a course of study that will allow the student to
transfer to a 4 year postsecondary institution. [ed rights holder ___________ student_____________]
 If student is eligible for the exemption, they are not required to accept the exemption and cannot be
denied enrollment in courses for which they are otherwise eligible.
[ed rights holder ___________ student_____________]
 If the student is not eligible to graduate under AB 216 upon initial evaluation; the student shall be
granted an exemption any time if he/she requests and qualifies for it in the future.
[ed rights holder ___________ student_____________]
 Once the AB 216 exemption has been granted it cannot be revoked by the school district.
[ed rights holder ___________ student_____________]
SIGNATURES AND PARENT CONSENT
1a
1b
1c
2a
2b
Agreement
I agree to all parts of the AB 216 determination.
I agree with the AB 216 determination, with the exception of:
I do not agree with this AB 216 determination.
Consent
I understand and agree that student is eligible for AB 216, and I am accepting the exemption.
The state’s graduation requirements will be the student’s new course of study
I understand and agree that student is eligible for AB 216; however I am NOT accepting the
exemption. The district’s graduation requirements of _____ credits will continue to be the
student’s course of study.
Authorization
Signature below is to authorize and confirm agreement with all the areas initialed above:
Signature:
Date:
/
/
Parent
Guardian
Surrogate
Educational Rights Holder
Adult Student
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