SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

Student Withdrawal Form

Student Name: _______________________________________________________________

Address: ___________________________________________________________________

City: __________________________________ State: _________ Zip: __________________

Grade: __________________ Sex: ____________ Entry Date: ________________________

Birth Date: _______________ Ethnicity: ___________ Withdrawal Date: _______________

Home Phone: __________________ Home District: __________ Withdrawal Code: _______

I intend to enroll my child in an appropriate educational program at the following school/district:

___________________________________________________________________________

Parent/Guardian Signature: ________________________________Date:______________

Day	Period	Course	Section	Description	Teacher	Room	Grade	Book Return
A	1							Y N
A	2							Y N
A	3							Y N
A	4							Y N
B	1							Y N
B	2							Y N
B	3							Y N
B	4							Y N

Reason for student withdrawal: __________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Administrator: ___________________________________ Date: ______________________

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