STUDENT WITHDRAWAL FORM

Student’s full name_______________________________________  Sex_____________

Social Security #_________________________________ Date of Birth______________

Grade___________

Date student withdrew from your system _______________

Administrator Signature at time of withdrawal__________________________________

Has this student been enrolled in a Special Ed. Program?        YES             NO

If yes, please provide us with a Special Ed. contact person and phone number.

Name and Title_______________________________________________

Phone Number______________________________

Has this student been enrolled in an Honors Program?      YES           NO

If yes, please list the subjects: _______________________________________________

                                                _______________________________________________