Student Withdrawal Form

School: Teacher:

Student’s Name: Male Female

Date of Birth: Grade: Withdrawal Date:

Parent/Guardian Name: Telephone:

Forwarding Address:

Please print clearly and include city, state and zip code.

Reason for Withdrawal:

Transfer to Another San Diego County School

Transfer to Private School

Transfer to Another California School

Transfer Out of State

Transfer Out of the United States – Name of Country

Home School

Other

Name of New School:

School Address (if known):

City, State, Zip Code:

Telephone: Fax:

This student has an active IEP, and is receiving Special Education services.

This student has a 504 Plan.

Parent/Guardian Signature Date

Student educational records will be forwarded to the receiving school upon written request.

For Office Use Only:

Date Student Records Sent Sent By

Please enter name and address of new school below.

11232 El Camino Real, San Diego, CA 92130 – Ph: (858) 755-9301- Fax: (858) 755-4361