Withdrawal Notification Form

Withdrawal Notification Form

2040 Avenue C * Bethlehem, PA 18017 * PH: 610-866-9660 FAX: 484-821-0646
Student Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Student's Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Day of Attendance

MonthDayYear
Date
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Phone Number:

Area CodePhone Number
Reason for Withdrawal(Please Explain):
Comments:
Comments:
Would you be interested in an exit interview with an administrator?:
If yes, how would you like to conduct the meeting?
Do you have an LVA Chromebook:
If yes, Date of Return:

MonthDayYear
Date
Name of New School:
Name of New School:
City/State:
City/State:
Parent/Guardian Print Name:
Date

MonthDayYear
Date
Parent/Guardian Signature
Administrator Signature:
Date

MonthDayYear
Date
For Administrative Use Only:

Date of Meeting:_____________________ Administrator:_____________________________

Feedback:___________________________________________________________________

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Should be Empty: