SECONDARY SCHOOL WITHDRAWAL FORM
STUDENT INFORMATON:
Name
(First Name)
(Middle Name)
(Last Name)
Student ID
Birthdate
/
Month
/
Day
Year
Date
Age
Grade
Parent/Guardian
SCHOOL INFORMATON:
Name of School
School Phone
Format: (000) 000-0000.
School Fax
Format: (000) 000-0000.
Address
School Address
Street Address Line 2
City/State/Zip Code
State / Province
Postal / Zip Code
ATTENDANCE INFORMATON:
Number of Days Enrolled
Number of Days Present
Number of Days Absent
Date Withdrawn
/
Month
/
Day
Year
Date
How many days are in the nine-weeks period?
Reason for withdrawal/Name and location of new school where student will be attending
ACADEMIC INFORMATION:
How many weeks has the student been present this school year?
What is the current quarter?
What day will the current semester end?
Please select all services currently provided to the student.
504 Accommodations
Special Education Services
Gifted Talented
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