Student Withdrawal Request
Upi Elementary School
Date of Request
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Student's Name
*
First Name
Last Name
Student's Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Level
*
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
Homeroom# / Teacher's Name
Reason for Withdrawal Request
*
Please Select
Enrolling to another GDOE school due to change of address
Enrolling to another GDOE school as an "Out-of-District" student
Relocating Off-Island
Enrolling to a Non-GDOE school
Homeschool
Other
Other Resons, Please specify.
What school are you transferring to?
School Name
Where are you locating to?
Please indicate City and State Name
New Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Effective Last Day
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date should be 2 days from the date of this request. There is a two day processing time.
PARENT ACKNOWLEDGEMENT:
Please read and initial the following statement for acknowledgement.
I am aware that it take two (2) working days from the date of request to process withdrawal documents
*
I am aware that I have two (2) calendar days from the date I receive the withdrawal packet to enroll my child at his/her new school.
*
I am aware that I must provide the school a copy of my child's itinerary.
*
I am aware that a proof of residency (for new location) MUST be provided upon receiving the my child's withdrawal form/packet.
I am aware that I must provide proof of enrollment/registration from child's new school.
*
Legal Parent/Guardian Name
*
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Legal Parent/Guardian Signature
*
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