Withdrawal Notification Form

Withdrawal Notification Form

2040 Avenue C * Bethlehem, PA 18017 * PH: 610-866-9660 FAX: 484-821-0646
Student Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Student's Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Day of Attendance*

MonthDayYear
Date
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Phone Number:*

Area CodePhone Number
Reason for Withdrawal(Please Explain):*

Relocation out of area/stateTransportationAcademic IssuesStudent BehaviorStudent ActivitiesDissatisfiedOther
Comments:*
Comments:*
Would you be interested in an exit interview with an administrator?:*
If yes, how would you like to conduct the meeting?
Do you have an LVA Chromebook:*
If yes, Date of Return:

MonthDayYear
Date
Name of New School:*
Name of New School:*
City/State:*
City/State:*
Parent/Guardian Print Name:*
Date*

MonthDayYear
Date
Parent/Guardian Signature*
Administrator Signature:
Date

MonthDayYear
Date
For Administrative Use Only:

Date of Meeting:_____________________ Administrator:_____________________________

Feedback:___________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
Should be Empty: