SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

Student Withdrawal Form

Date: __________________

I am withdrawing my child, ______________________________, grade_______, from XYZ

Charter School. My child’s last day will be ________________________________________

___________________________________ _____________________________________

Signature Relationship to Child

___________________________________ _____________________________________

School Secretary Withdrawal Date

III. 12