S HENENDEHOW

CENTRAL SCHOOLS A Notice of Student Withdrawal Form

High School East
High School West

Student’s Name
Last Name First Name Middle Name
Student’s Grade Student’s Date of Birth

Reason for Withdrawal: Please check the appropriate information below

Moving out of District Is the entire family moving? Yes No
If YES, please indicate information below
Name of new school district
Address of new school district
New home address
If NO, please indicate information below
Name of person the student will reside with
Relationship with student
New home address
Name of new school district
Address of new school district

Transferring to Private School

Name of Private School

Transferring to Home Schooling

Dropping Out (Student must finish the school year in which he/she turned 16 years old
Does student plan on pursuing a G.E.D.? Yes or No
If the student is dropping out, please have the student sign below:
Student’s Signature____________________________________ Date______________________

______ Other Specify __________________________________________________________

Student’s Last Day of Attendance at Shenendehowa

Does student currently receive special education services? Yes No

I give permission for the exchange of information

concerning my child between the Shenendehowa
Central School District and
(name of new school)

(address) (City) (state) (ZIP code)

***I understand that all school fees must be paid in full and all school issued books must be
returned prior to my child(ren) being withdrawn from school.
Parent / Guardian Signature Date
Parent / Guardian Printed Name

Parent / Guardian Relationship to Student

Parent / Guardian Phone Number