Withdrawal Form - Scituate Public Schools printable pdf download

Withdrawal Form - Scituate Public Schools

SCITUATE PUBLIC SCHOOLS

WITHDRAWAL FORM

Date of Request:____________

Student’s Full Name:____________________________________________________________

Date of Birth:______________ Current Grade:______________



Last day attending current school: _______________ or End of current school year

Student withdrawing from:

Cushing Elementary School

Hatherly Elementary School

Jenkins Elementary School

Wampatuck Elementary School Gates Intermediate School

Scituate High School

Please indicate reason for withdrawal:

 My child will be attend a new public school

 I will be home schooling my child

 My child will be attending a private school

 My child will be attending a Hi Set (GED) program

Moving out of state/country

 Other ______________________________

Student’s New School: Name: _______________________________________________

Address: ______________________________________________

City__________________________ State________ Zip _________

Phone: __________________ Fax (if known): ________________

Contact Name: __________________________________________

If student is moving out of Scituate:

Student’s New Address __________________________________________________

City______________________ State_______ Zip _________

I hereby withdraw my son/daughter from Scituate Public Schools and grant

permission to release transcripts, medical, guidance, and special education

records to the above school.

__________________________ ________

_____________________________

Parent Signature

Date

Student Signature (if over 18 yrs. of age)

Please submit completed form to school principal or Gates/SHS guidance counselor.

__________________________________________________________________________

School Office Use:

 Student has returned all school owned property. Signed _________________________

Ver. 2015.6

Withdrawal Form - Scituate Public Schools