WITHDRAWAL FORM

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 By completing and signing this form you acknowledge that your student will be withdrawn from BPS.
HOW MANY STUDENTS ARE YOU WITHDRAWING FROM BPS?

ONETWOTHREE
STUDENT'S LEGAL NAME*

First NameLast Name
STUDENT'S DATE OF BIRTH*

MonthDayYear
Date
CURRENT SCHOOL*
CURRENT GRADE*
STUDENT ID#
STUDENT'S LEGAL NAME 2*

First NameLast Name
STUDENT'S DATE OF BIRTH 2*

MonthDayYear
Date
CURRENT SCHOOL 2*
CURRENT GRADE 2*
STUDENT2 ID#
STUDENT'S LEGAL NAME 3*

First NameLast Name
STUDENT'S DATE OF BIRTH 3*

MonthDayYear
Date
CURRENT SCHOOL 3*
CURRENT GRADE 3*
STUDENT3 ID#
REASON FOR WITHDRAWAL*
Please provide the name and address of the new school your child will be attending.
NEW ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NEW SCHOOL/DISTRICT*
NEW SCHOOL/DISTRICT
NEW SCHOOL/DISTRICT FAX OR EMAIL
NEW SCHOOL/DISTRICT FAX OR EMAIL
WHERE WILL YOU BE GOING ON THE EXTENDED LEAVE?
EXPECTED DATE OF RETURN
STATE REASON FOR WITHDRAWAL
PARENT/GUARDIAN NAME*

First NameLast Name
State law requires students and/or their parents to provide a complete school record upon enrollment in a new district. By clicking here you authorize the release of all school records. These include, but are not limited to, health records (immunizations, physical), academic records (MCAS Scores, Transfer Grades, Transcript, Access/WIDA Scores) Special Education/Evaluation Reports (Psychological, I.E.P., etc.) and discipline records.*

YES
Last Day attending Brockton Public Schools*

MonthDayYear
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
PARENT/GUARDIAN EMAIL
example@example.com
PARENT/GUARDIAN PHONE*
Please enter a valid phone number.
UPLOAD PARENT/GUARDIAN PHOTO ID*

Cancelof
Should be Empty: