Withdrawal Form

Withdraw Form

Trumbull Career & Technical Center
Date

MonthDayYear
Date
Student ID*
Last name*
First name*
Grade*
Homeschool*
Program*
Program teacher email
example@example.com
Program Supervisor*
Program Supervisor email
example@example.com
Program Secretary*
Program Secretary email
example@example.com
Withdrawal date

MonthDayYear
Date
Counselor*
Counselor email
example@example.com
IEP*
EMIS reason for withdrawal*

(40) Transferred to another school outside of Ohio(41) Transferred to another Ohio school district(42) Transferred to a private school(43) Transferred to home schooling(45) Transferred by court order/adjudication or placed in an institution operated by DOYS(51) Verified medical reasons (Dr.'s authorization on file)(52) Death(71) Withdrawn due to truancy/nonattendance(72) Pursued employment/work permit (Supt. approval on file)(73) Over 18 years-of-age (withdrawing from school)(74) Moved; not known to be continuing(75) Student completed course requirements but did not pass statewide assessments(81) Student Reported in Error (Never should have been reported)(99) 99 Completed High School Graduation Requirements;IEP student taking diploma (took all appropriate statewide assessments)Expelled
Surveyed reason(s) for withdrawal (check all that apply) Reasons indicated on the in-school survey will not appear on the final withdrawal record.*

Program did not meet expectationsProgram curriculum too easyProgram too hardAcademic courses did not meet expectationsAcademic curriculum too easyAcademic curriculum too hardConflict with program staffConflict with academic staffConflict with other studentsTransportation problemsUnable to participate in home school activitiesMisses contact with homeschoolUncomfortable with TCTC environmentCredit shortageFailing programFailing academic class(es)Attendance problemsProblems complying with TCTC rules/policiesParent requestNo showRelocationOther (explain in comments)
If enrolling in another school, list name of school
English teacher*
English Email
example@example.com
Math teacher*
Math Email
example@example.com
Government teacher*
Goverment Email
example@example.com
Science teacher*
Science Email
example@example.com
The student is eligible for a refund or owes money for the following reasons*

Student returning to homeschoolStudent changing programsOther
Comments
How did the guardian notify TCTC?
Supporting document from guardian

Copy of email, notes, etc. from guardian
Cancelof
Conference outcomes
Grade verification sheet, other documents related to withdrawal

Cancelof
This withdrawal form is ready for the next steps, and the above fields are ready to be locked.*

Yes
Program Teacher

This section is for Program teacher only.
Program percentage
Enter Student grade percentage
Program materials returned
Program list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
English Teacher

This section is for English teacher only.
English percentage
Enter Student grade percentage
English materials returned
English list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
Government Teacher

This section is for Government teacher only.
Government percentage
Enter Student grade percentage
Government materials returned
Government list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
Math Teacher

This section is for Math teacher only.
Math percentage
Enter Student grade percentage
Math materials returned
Math list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
Science Teacher

This section is for Science teacher only.
Science percentage
Enter Student grade percentage
Science materials returned
Science list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
iPad Return

Please mark yes/no if all items have been returned.
Apple iPad
Apple iPad cost
Power brick
Power brick cost
Charging cord
Charging cord cost
Case
Case cost
Apple MacBook

Please mark yes/no if all items have been returned.
Apple MacBook
Apple MacBook cost
Power brick
Power brick cost
Charging cord
Charging cord cost
Device carrying case/bag
Device carrying case/bag cost
Mobile Wifi hotspot

Please mark yes/no if all items have been returned.
Hotspot returned
If student was not issued a hotspot please select N/A.
Mobile wifi hotspot cost
Media Center

Please mark yes/no if all items have been returned.
Media Center materials have been returned
If student was not issued materials please select N/A.
Materials description
Total material cost
Secretary
I the Program Secretary have reviewed all of the information is correct and completed. This form is ready for Supervisor review.

Yes
Item 1
Price of item 1
Item 2
Price of item 2
Item 3
Price of item 3
Item 4
Price of item 4
Item 5
Price of item 5
Item 6
Price of item 6
Item 7
Price of item 7
Item 8
Price of item 8
Item 9
Price of item 9
Item 10
Price of item 10
Total amount due of listed items
Should be Empty:

Withdraw Form

Program Teacher

English Teacher

Government Teacher

Math Teacher

Science Teacher

iPad Return

Apple MacBook

Mobile Wifi hotspot

Media Center

Secretary