School Withdrawal Form
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1***OFFICE USE ONLY***
Date of Entrance:
Immunization Record Received:
_____Student ID: _______________Teacher:________________
Proof of Residency Received:
Birth Certificate Received:
_____SASID: ___________________Home Room:____________
Previous Records Received:
Counselor: ______________________
_____Locker /Advisory:_______________
___________
Date:
Grade Entering:_____
STUDENT INFORMATION (Complete Legal Name):
First: _____________________________ Full Middle Name: ___________________ Last: _________________________________
Nickname: __________________________ Gender: (Circle one) M
F
Date of Birth: ________________
City of Birth: __________________________
State: _____
Country: __________________________
Address: _______________________________________ City/Town (Residence): _______________________ Zip: ____________
Mailing Address if Different: ___________________________________________________________________________________
Former School: __________________________________ __________________________ Type:____________________________
Name of School
City/State
Public/Private/Charter
Has student ever attended public school in Massachusetts? ___________ In Hopkinton? _____________
(If different than Former School information)
Ethnicity: (Circle one)
Non-Hispanic
Hispanic
Race: (Circle all that Apply)
American Indian or Alaskan Native, Asian, White, Native Hawaiian or other Pacific Islander,
Black or African American
Parent(s) Status:
( ) Married
( ) Divorced
( ) Separated
( ) Other ________________________________
Child is living with:
( ) Both parents ( ) One Parent: Mom or Dad
( ) Other: _______________________________
Custodial Parents:
( ) Mother
( ) Father
( ) Other: ______________________________________________
Is there any court order in place? ( ) Yes ( ) No
Divorce Decree on file in school: ( ) Yes ( ) No
If parents are divorced, does the non-custodial parent receive information on the child? ( ) Yes ( ) No
If so, what address should it be sent to? (Court order must be in file in the school):
Mother’s/Guardian Information:
Name: _______________________________________ Home Phone #: ___________________Cell Phone #: __________________
Employer: _____________________ Work Phone #: ____________ Email Address:__________________________________
(required)
Address if different from above: _________________________________________________________________________________
Father’s/Guardian Information:
Name: _______________________________________ Home Phone #: ___________________Cell Phone #: __________________
Employer: _______________________Work Phone #: _____________ Email Address: _____________________________
(required)
Address if different from above: _________________________________________________________________________________
Alert Now Phone Number (Parent #’s to be called in case of emergency dismissals, school closings, etc):
#1: ________________________
#2: ______________________
Person(s) to Notify in Case of Emergency/Illness if Parents cannot be reached:
1. Name: ____________________________________ Home #: _______________________ Cell #: ___________________
Relationship to Student: ________________________ Permitted to pick up student: ______________________
2. Name: ____________________________________ Home #: _______________________ Cell #: ___________________
Relationship to Student: ________________________ Permitted to pick up student: ______________________
Student Educational Information:
Has your child received special education services or accommodations through an Individualized Education Plan (IEP) or Section 504:
( ) Yes ( ) No
Member of Military Family ( ):
Is the student the child of:
1) An Active duty member of the uniformed services, National Guard and Reserve on active duty orders
2) A member or veteran who has been medically discharged or retired for (1) year
3) A members who died on active duty
( ) Yes
( ) No
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