343.4 Exhibit 1

School District of Prairie Farm

YOUTH OPTIONS PROGRAM COUNSELOR FORM

To: Principal, Prairie Farm High School

From: _______________________________, Counselor

This form should be filed by the counselor with the principal as soon as a student’s application for participation in the post-secondary enrollment options program is returned to the counselor.

Student: _______________________________________

Grade: ______________

Date making request:_________________________________________

Student’s regular graduation class: ____________________________

Date of requested post-secondary enrollment option:_______________________

Cumulative G.P.A.

F’s Last Semester

F’s Current Grading Period

Reasons for request:

Counselor Recommendation: