District Withdrawal Form - West Clermont Local Schools
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2DISTRICT
WITHDRAWAL FORM
Building ______________________________________
SSID ____________________________
Student Name _________________________________
ID # _____________________________
Grade _____________
Date of Birth __________________
Withdrawal Date __________________
For students transferring to another school: Permission is hereby granted for the West Clermont School District to
release ALL records of the student, whose name is listed above, to the following school:
Name of New School _________________________________________________________________________________
School Address _____________________________________________________________________________________
Parent/Guardian Signature __________________________________
Cell Phone ______________________________
New Address _______________________________________________________________________________________
This permission only applies to the school listed in the above section.
==================================================================================================
CAFETERIA CHARGES
PAID:
YES
NO
Authorized Signature ___________________________
MEDIA CENTER CHARGES
PAID:
YES
NO
Authorized Signature ___________________________
SCHOOL FEES/FINES
PAID:
YES
NO
Authorized Signature ___________________________
EXTRACURRICULAR FEES
PAID:
YES
NO
Authorized Signature ___________________________
Textbooks Returned
Subject Taken
Grade Earned
Yes or No
(this semester)
(this 9 weeks)
If no, provide book title
Teacher Signature
Principal Signature ________________________________________
Date ___________________________
Counselor Signature _______________________________________
Date ___________________________
Office Use Only
____ Withdrawal Code Used
____ Office Personnel Initials
____ Records Request Received
____ Date Received
____ Records Sent
____ Date Sent
If you are leaving West Clermont for another school, please complete the back of this form.
PS-060 (7/13)
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