Student Transfer Rescission Form printable pdf download

STAFFORD COUNTY PUBLIC SCHOOLS

STUDENT TRANSFER RESCISSION

INSTRUCTIONS: This form is used only to rescind an approved Student Transfer so a student can return to

his/her base (assigned) school. The parent/guardian must complete, sign, and submit this form to the school the

student is currently attending. Submit a separate form for each child.

PART I

STUDENT INFORMATION (please print)

Student Name: _____________________________________________________________________________

LAST

FIRST

Base School: ______________________________

School Currently Attending: _______________________

(Your assigned school)

(School you transferred to)

School Year Rescission Takes Effect: __________ ----- ___________

Grade: _________________________

Parent/Guardian Name: ____________________________________

Home Phone: ___________________

Address: ________________________________________________

Other Phone: ___________________

STREET

APT

________________________________________________ Email: _________________________

CITY

STATE

ZIP CODE

Does your student receive any special programming or services as part of his/her school program? Yes

If yes, please describe: ________________________________________________________________________

Please note: If the program or services required by the student are not available or are at capacity, the student may not be able to return to

his/her base school.

Parent/Guardian:

I understand the purpose of this form is to rescind the student’s transfer to the requested school. Once the

rescission is processed, the student will return to his/her base school.

High school students may lose their eligibility to compete in VHSL-sanctioned activities by returning to

their base school. If you have concerns about eligibility, contact the school’s Athletic Director prior to

submitting this form.

This rescission is final. The parent/guardian must complete and submit a new Student Transfer Application

if the student wishes to return to the requested school or transfer to a new school.

Parent/Guardian Signature: ______________________________________________ Date: _________________

PART II

SPECIAL EDUCATION/ADMINISTRATIVE RECOMMENDATION (for office use only)

□

Approve

Deny

Comments:_____________________________________________________________

Signature: ____________________________________________________________Date:__________________

PART III

CENTRAL OFFICE USE ONLY

Date received: __________________

Received by: ____________________ Code: ___________________

Student Transfer Office

Revised 1/1/11

Student Transfer Rescission Form

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