Notification of Withdrawal

Crowley County School District Re 1-J

Ordway, co 81063 (719)267-3117
Student's Full Name*
Date*

MonthDayYear
Date
Current Grade
Gender*
SASID Number
Parent/Guardian Name*
Work Phone Number*
Email Address*
example@example.com
Anticipated last date of attendance at current school*

MonthDayYear
Date
Today's date*

MonthDayYear
Date
First scheduled date of attendance in new educational program*

MonthDayYear
Date
Classroom
Lunch
Library
Reason for Withdrawal (Exit Code)*

Transferring to another public school within the same district (11)*Receiving Home-Based Instruction/home schooling (16)Transferring to another Colorado Public School outside the district (13)*Long term illness/injury (30)Transferring to a public school outside of Colorado (14)*Drop out/discontinued schooling (40)Transferring to a private school (15)*Expelled (50)Enrolling in a GED program not run by a school district or BOCES (17)*Other
*Please provide the following information if the student is transferring to another school or program
Name of new school/program
Address

Street Address

Street Address Line 2

CityState

Postal / Zip CodeCountry (if other than US)
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: