Williamsburg James City County Public Schools Elementary School Withdrawl Form
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1Williamsburg-James City County Public Schools
ELEMENTARY SCHOOL WITHDRAWAL/TRANSFER FORM
Elementary School Name, Address, Phone & Fax Numbers
Student _________________________________________________________________ Date of Birth_____________
Last
First
Middle
Student ID No.___________________ Grade_____ Withdrawal Date______________ 4-Digit Withdrawal Code:
W 1__ __: Transfer to another classroom in the school
W 6 5 0:
Death of student
W 2__ __: Transfer to another WJC School/Charter School
W 7__ __: Graduated or Completed course requirements
W 3__ __: Transfer to Private School
W 8 8 0:
Discontinued schooling (drop-out)
W 4__ __: Transfer to VA Public School Outside WJC
W 9__ __: Absent 15 consecutive days-expected to return
W 5__ __
Transfer to Public School Outside Virginia
W 0 1 6:
Enrolled in ISAEP for GED Prep Program
:
Reason for Withdrawal_____________________________________________________________________________
Days Present This School Year _____________
Days Absent This School Year _____________
Teacher’s Name______________________________________________________________________
Reading Level and Grade Equivalent_____________________________________________________
Math Level and Grade Equivalent
_____________________________________________________
Special Services Provided _____________________________________________________________
Parent/Guardian Name________________________________________________________Phone________________
New Home Address________________________________________________________________________________
Name/Address of New School________________________________________________________________________
________________________________________________________________________________________________
_______________________________/__________
______________________________/___________
Parent/Guardian Signature
Date
Principal/School Representative Signature
Date
.
Staff: Please initial to confirm notification
Media Center ______
Nurse ______
Reading Spec.______
A copy of this withdrawal form should be taken to the new school to assist in registration.
The student’s educational record will be forwarded to the receiving school upon request.
Revised 5/08 alm
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