Student Withdrawal
This form is for the parent or legal guardian of a student to submit a request to withdraw them from Peak Prep Pleasant Valley
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Relationship Status
*
Please Select
Parent
Legal Guardian
Please note in order to complete this form you must be the parent or legal guardian of this student
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Student Name
*
First Name
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Grade
*
Please Select
TK
K
1
2
3
4
5
6
7
8
9
10
11
12
Student's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Withdrawal
*
-
Month
-
Day
Year
Date
Reason for Withdrawal
*
Please Select
New Public School
New Private School
Moving out of State
Moving out of Country
What school will the student be attending next?
*
By signing below, I confirm that I am the parent or guardian of the student named above and acknowledge the withdrawal of the student from the school. I also certify that the information provided regarding the student's new school or destination is accurate and complete.
*
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