BPS WITHDRAWAL FORM

BPS WITHDRAWAL FORM
Parents/Guardians of all students withdrawing from the Brockton Public Schools (BPS) must complete this form and report where they will be next enrolled. By completing and signing this form you acknowledge that your student will be withdrawn from BPS.
STUDENT'S NAME *
DATE OF BIRTH *

Month Day Year
Date
CURRENT SCHOOL *
CURRENT GRADE
STUDENT ID #
STUDENT'S NAME
DATE OF BIRTH:

Month Day Year
Date
CURRENT SCHOOL
CURRENT GRADE
STUDENT ID#
STUDENT'S NAME
DATE OF BIRTH

Month Day Year
Date
CURRENT SCHOOL
CURRENT GRADE
STUDENT ID#
REASON FOR WITHDRAWAL *
If your student is withdrawing from BPS and plans to return, you will be required to provide proof of residency upon the student's return to Brockton. Visit our registration page for more information.
If you are going on an extended leave, where will you be visiting?
EXPECTED RETURN DATE TO BROCKTON

Month Day Year
Date
NEW ADDRESS *
NEW SCHOOL DISTRICT
EFFECTIVE DATE OF WITHDRAWAL *

Month Day Year
Date
As agreed to in the Brockton Public Schools 1:1 Device Agreement, the student laptop (with a replacement value of $350) is the property of the Brockton Public Schools and must be returned immediately upon request. Upon a student’s withdrawal from the Brockton Public Schools all school owned books, materials and electronic devices must be returned and inventoried at the school. Please contact your child’s principal to arrange for the device return.
PARENT/GUARDIAN SIGNATURE

Clear
Márcia Andrade Serpa, Director

School Registration & Parent Information Center

60 Crescent Street Brockton, Massachusetts 02301
PARENT/GUARDIAN EMAIL:
example@example.com
PARENT/GUARDIAN PHONE: *
Please enter a valid phone number.
PARENT/GUARDIAN NAME:
Should be Empty: