Revised 3/2013
NORTH ROYALTON CITY SCHOOLS STUDENT WITHDRAWAL FORM
North Royalton Middle School
North Royalton High School
14709 Ridge Road
14713 Ridge Road
North Royalton, Ohio 44133
North Royalton, Ohio 44133
440-582-9120
440-582-7801
Fax 440-582-7229
Fax 440-582-7337
Section A. Name of Person Completing Withdrawal Form: ____________________________
Date Completed _________________
To be completed by the parent or legal guardian (or the student if age 18 or older).
Student’s Name:
Grade:
Last day of attendance:
Home Phone:
Cell Phone:
(
)
(
)
Reason for withdrawal:
New Home Address:
Where will your child attend school?
New school phone number:
***THIS SECTION MUST BE COMPLETED IN THE PRESENCE OF THE ATTENDANCE SECRETARY OF THE BUILDING THE STUDENT
IS BEING WITHDRAWN FROM***
All information is complete and correct. I am the child’s custodial parent or legal guardian, or I am the student age 18 or older. I grant
permission to my child’s school to release records to my child’s new school.
Signature(s) of Parent/Guardian
PRINT Parent/Guardian Name(s)
Date Signed
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For Staff Use Only:
Please sign in the space provided and indicate any missing book(s)/cost. Return this form to the office when complete.
Period/Subject
Current
BOOK(S) RETURNED?
Teachers Signature
Grade
(Name of missing book)
Cost
1.
Yes
No
2.
Yes
No
3.
Yes
No
4.
Yes
No
5.
Yes
No
6.
Yes
No
7.
Yes
No
8.
Yes
No
9.
Yes
No
10.
Yes
No
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For Office Use Only:
01 Completed Course Requirements
42 Transferred to a Private School
71 Withdrew due to Truancy/Non-attendance
40 Transferred Outside Ohio
43 Transferred to Home Schooling
72 Pursued Employment/Work Permit
41 Transferred to Another Ohio School District
45 Transferred by Court Order
73 Over 18 years of Age
74 Moved; Not known to be continuing
Withdrawal Code: _______________
DASL Student ID Number: _______________
Signature of person entering withdrawal into system: _______________________________________________ Date: _________________________
Route to the following (please initial your area)
Media Center:
Fees:
Locker #:
Withdraw from CVCC:
Counselor:
Unit Principal:
Principal: ______
Please return completed form to Attendance Secretary