WITHDRAWAL NOTIFICATION

PLEASE NOTE: THIS FORM IS NOT CONSIDERED AN OFFICIAL WITHDRAWAL. YOUR STUDENT IS NOT OFFICIALLY WITHDRAWN UNTIL WE HAVE RECEIVED APPROPRIATE NOTIFICATION OF ENROLLMENT FROM THEIR NEW SCHOOL.

STUDENT STUDENT First Last
GRADE
SCHOOL YEAR
SCHOOL WITHDRAWING FROM
If you choose "Other" to the question above, please name current school.
LAST DATE OF ATTENDANCE WITH BCSD LAST DATE OF ATTENDANCE WITH BCSD / MM / DD YYYY
NEW SCHOOL DISTRICT
NEW SCHOOL NAME
START DATE WITH THE NEW DISTRICT (if known) START DATE WITH THE NEW DISTRICT (if known) / MM / DD YYYY
NEW HOME ADDRESS (if applicable) NEW HOME ADDRESS (if applicable)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
I understand that my student is required to return all textbooks, materials, library books or any other materials belonging to the Berea City Schools before this withdrawal is considered complete. I understand that if there are any outstanding materials, etc. they will be considered outstanding fees.
NAME OF THE PERSON WITHDRAWING STUDENT: NAME OF THE PERSON WITHDRAWING STUDENT: First Last
RELATIONSHIP TO STUDENT
Phone Phone - ### - ### ####
Email
BY TYPING MY NAME, REPRESENTS MY ELECTRONIC SIGNATURE.
Date Date / MM / DD YYYY