DO NOT ACCEPT ANY STUDENT FOR ENROLLMENT WITHOUT A SENDING SCHOOL WITHDRAWAL FORM.
Student must not be enrolled in the receiving school with the same date as specified on this withdrawal form.
PULASKI COUNTY SPECIAL SCHOOL DISTRICT
ELEMENTARY SCHOOL WITHDRAWAL FORM
Student:
(Last Name)
(First Name)
(Middle Name)
Student ID: Birthdate: Age: Grade:
STUDENT INFORMATION:
Parent/Guardian:
Name of School: Teacher:
School Address: City/State/Zip Code:
SCHOOL INFORMATION:
School Phone:
Number of Days Enrolled: Number of Days Present: Number of Days Absent:
# Days Absent this nine-week period:
Date Withdrawn:
ATTENDANCE INFORMATION:
Reason for withdrawal/Name and location of new school where student will be attending:
ACADEMIC INFORMATION:
SCIENCE
SOCIAL STUDIES
LANGUAGE
SPELLING
MATH
READING
4321
PAGE
COMPLETED
LEVELTITLE OF BOOKPUBLISHER
SUBJECT
REPORTING
PERIOD
Grading Scale: A = 90-100 B = 80-89 C = 70-79 D = 60-69 F = 59 and below
CHARGES OWED:
CAFETERIA:
$
MEDIA CENTER:
$
FUNDRAISER:
$
The information reported on this form is official and agrees with the records of our school. For a complete record of test results and this student's
work, please contact our school office at the number listed above.
Teacher's Signature: Date:
Date:Principal's Signature:
COMMENTS:
Division of Equity and Pupil Services Revised August 2008
Current Services Received:
Special Education Services 504 Accommodations Talented & Gifted Program
