Student Withdrawal Request
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2Enrollment Center Use Only
Student Withdrawal Request
_____________________
Student ID
_______________________
State ID
___________
Cohort year if high school
Student Last Name __________________________________________ First Name______________________________
School withdrawing from _______
________________________
Grade ______________
Last day student attended this school ________________________________
Date of Birth _____________________
Change of Address
Magnet/Charter/Optional School Acceptance
Withdrawal Reason:
(please circle one)
Expectations Not Met
Safety Concerns
Transportation
Discipline
Not on Track to Graduate
Other:
____________________
Transferring to:
Another MNPS School
Private School
Virtual School
Home School
(please circle one)
Out of County
Out of State
Out of Country
Other:
______________________________________________
Next Planned School of Enrollment
School Name
City, State
Parent Comment: ___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I understand and acknowledge that withdrawal from an MNPS Magnet/Optional /Charter School will result in forfeiture
of the student’s assignment at such school and that my student may not have the option to enroll in another MNPS
Magnet/Optional/Charter school until the next school year.
I understand and acknowledge that outstanding fees, fines, or unreturned school property such as textbooks, library
books, instruments, uniforms, or equipment may results in financial charges and/or withholding of student records.
_________________________
Parent/Guardian Phone #
Required- Attach Parent/Guardian Photo ID
_________________
Parent/Guardian Name
Parent/Guardian Phone Call
_________________
Parent/Guardian Signature
**************************************************************************************************
MNPS Use Only
Withdrawal Entered in SMS by______________ W/D date ___________ W/D code______ Charter/Magnet Contacted: ___________
11/07/2014
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