Wm. Mason High School Student Withdrawal Form
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1MCS‐ 339a Rev. 06/11
STUDENT WITHDRAWAL FORM
Wm. Mason High School
6100 Mason‐Montgomery Rd., Mason, OH 45040
Phone: (513) 398‐7896 Fax: (513) 336‐6823
Student Name: ___________________________ ID No. ___________ Grade: _________
Reason for Withdrawal: __________________________ Last Day in Attendance __________
Parent/Guardian Name: _________________________________________________________
New Address: _________________________________________________________________
Remaining in the State of Ohio: _____ Moving out of Ohio: _____ Moving to the state of: _____
If remaining in Ohio, what school district will student attend? _______________________________
Name and Address of New School: _________________________________________________
I hereby give permission to withdraw my child from Wm. Mason High School. I understand that my child’s
schedule will be dropped and if a decision is made to return to Mason High School, registration at Mason
City Schools’ Central Office will be required.
____________________________________________________________
__________________
Parent/Guardian Signature
Date
The Mason City School District will gladly provide an official transcript once all financial obligations have been paid,
and this form is signed by the parent/guardian.
Student: Please complete following information before turning into the Guidance Department
NOTICE TO STAFF: This student is withdrawing from school. Please complete the following:
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