Intent to withdraw

Student's Name

Birth Date

Age

Grade Level

Official Withdrawn Date

Parent/Guardian Name

Telephone

Forwarding Address (include city, state, zip)

Reason for Withdrawal

If selected other, please specify below:

If transferred outside the US, list country below:

Transfer to:

School

School Address

By typing my name below, I hereby certify that I am fully authorized by law to make the preceding request.

Submission Date

By checking here, I understand that processing a withdrawal takes 48 hours from date of submission.

I certify that the information above is accurate and correct