LS Student Withdrawal Form

LS Student Withdrawal Form

WWW.LSRHS.NET
Today's Date*

MonthDayYear
Date
Student's Withdrawal Effective Date:*

MonthDayYear
Date
House
Year of Graduation*
year only
Student Name*

First NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Withdrawal*
New school name and address*

School name

Address

CityState / Province

Postal / Zip Code
Current students who are withdrawing should download and save any school work from their Google account. Google accounts are deactivated on the withdrawal date provided on this form.
YesNo
YesNo
NOTICE ON TRANSFER TO OTHER SCHOOLS

Pursuant to 603 CMR 23.07(g), notice is hereby given to parents and eligible students that Lincoln-Sudbury Regional High School will forward the complete school record of a transferring student to public schools in which the student seeks or intends to enroll. Such transfer of records can take place without consent of the parent or eligible student. Students enrolling in private schools require specific parent permission for record release. Your Lincoln-Sudbury school records, with the exception of your official transcript, will be destroyed seven years after withdrawal. For more information regarding Federal Laws – FERPA http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html
Parent/Guardian Nam*

First NameLast Name
Address- if different from student

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
By signing below you acknowledge and understand any courses your student is currently enrolled in will not be quarranteed if re-enrollment occurs. In addition, if you and your student decide to return to Lincoln-Sudbury please follow the enrollment process which can be found on the Registrar page on the LS website.
Parent/Guardian Signature*

Signature
Should be Empty: