Student Withdrawal Form

Student Withdrawal Form

This form is used to formally notify Roseville Community Learning Center (RCS) of a student’s withdrawal from the program. Submission of this form helps us ensure accurate records, billing adjustments, and a smooth transition.
Student Information
Name

First NameLast Name
Program Currently Enrolled In
Family Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Withdrawal Details
Last Date of Attendance

MonthDayYear
Date
Reason for Withdrawal

Other
Optional Message to RCS (Sharing is optional, but feedback is always appreciated and helps us improve our program.)
Acknowledgements
I understand that this form serves as formal notice of withdrawal from RCS.

I acknowledge that program fees, and notice requirements are governed by the Participation Agreement and any applicable addendums.

I understand that submission of this form completes the withdrawal process.

I understand that withdrawal may impact charter funds already issued to RCS or vouchers that have been submitted or are in process. If charter purchase orders or vouchers are canceled due to withdrawal or reduction, families remain fully responsiblefor any unpaid tuition balance

By signing below, I confirm that the information provided is accurate and that I am formally withdrawing my child from Roseville Community School.
Signature
Should be Empty:

Student Information