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 By completing and signing this form you acknowledge that your student will be withdrawn from BPS.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 (MM-DD-YEAR)

CURRENT SCHOOL *

CURRENT GRADE

STUDENT ID #

STUDENT'S NAME

DATE OF BIRTH (MM-DD-YEAR)

CURRENT SCHOOL

CURRENT GRADE

STUDENT ID#

STUDENT'S NAME

DATE OF BIRTH (MM-DD-YEAR)

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?

NEW ADDRESS *

NEW SCHOOL DISTRICT

I authorize the release of school records to the new school district identified in this form.

YES

EFFECTIVE DATE OF WITHDRAWAL *

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: