Form Spi0023 - Certificate Of Withdrawal Form (Pre K

Form Spi0023 - Certificate Of Withdrawal Form (Pre K - 12)

INITIATED BY: _____________

___________________________

St. Lucie Public Schools

CERTIFICATE OF WITHDRAWAL FORM (Pre K – 12)

STUDENT’S NAME_________________________________ RACE ___ SEX ___ GRADE ___ ID#_______________________________ STUDENT’S DOB ____________

SCHOOL _____________ NEW ADDRESS, IF KNOWN___________________________________ NEW CITY _____________________ NEW STATE _________

Transfer In County ____; Transfer

WITHDRAWAL REASON:

Out of County ___; ESE Program ___; Alt Ed Placement ___; Magnet School ___; Home School ___;GED

___ Adult High School ___ DJJ Program ___ Non-Attendance___ Marriage _____ Termination of Enrollment ____ Other _________________________________________

SPECIAL PROGRAM/PLAN: (Please Circle) ESE

Program: Primary Exceptionality______________

TITLE 1

MIGRANT 504 PLAN AIP

ESOL

LEP

NEW SCHOOL (IF KNOWN) __________________________________ WITHDRAWAL DATE_____________ WITHDRAWAL CODE_____

B: 80 – 90; C: 70 – 80; D: 60 – 70; F: 0 – 59; I: Incomplete Grades K – 2: S: Satisfactory; P: Progress Made; N: Not Progressing as Expected

GRADE KEY: A: 90-100;

Grades 1 and 2 also have a grade of E - Excellent

SUBJECT

TEACHER

GRADE TO

BOOKS

TITLE OF BOOK(S) NOT

PRICE

Prior Obligation: ___________

DATE

RETURNED

Yes

Current Obligation: _________

Yes

Total Amount Due: $ ________

Yes

ID Badge Returned: Yes

Attendance

Yes

Days Membership_______

Yes

Days Absent ___________

Days Present ___________

Yes

A Truancy Petition has been filed in

Yes

Circuit Court: ___Yes

____No

I understand that terminating school enrollment is likely to reduce my potential earnings and may affect my eligibility for temporary cash assistance

through the Department of Children and Families and my eligibility to obtain or maintain a driver’s license.

Student’s Signature ____________________________ Date _________ Parent’s Signature ______________________ Date ______

Withdrawal interview conducted by phone by _______________________ title __________________ on ____________ with the

student and parent

student only

parent only because of the student and/or parent(s) inability to come to the school and complete this form. This staff person states that all

information recorded on this form reflects the statements of the parent(s) and/or student at the time of the interview.

Signature of School Staff Member: ___________________________ Date: ________________

Administrator’s Signature _____________________________________ Date ________________

White: Cumulative Folder

Canary: Parent/Guardian

SPI0023 Rev. 2/03

Form Spi0023 - Certificate Of Withdrawal Form (Pre K - 12)

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