Syracuse University

Liberty Partnerships Program

Student Exit Form

Name:

__________________________________________________

Student ID: ____________________

School:

____________________
Reason for Separation
(Check one)

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Unknown
No longer interested
Unable to contact student
Transferred to another school
Uncooperative
Suspended
Schedule conflict
Transferred to a non-targeted school
Aged out of program
No longer recommended for LPP
Other: ________________________________________________
______________________________________________________

Signature: _________________________________
Date:

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