Student Last Name ____________________________________ First Name ____________________________________
School Withdrawing from ________________________________________________________ Grade ______________
Last day student attended this school __________________________________
Withdrawal Reason:
⬜ Change of Address
Date of Birth _______________
⬜ Magnet/Charter/Optional School Acceptance
(please ✔ one)
⬜ Expectations Not Met
⬜ Safety Concerns
⬜ Not on Track to Graduate
Transferring to:
⬜ Transportation
⬜ Discipline
⬜ Other: ________________________________________
⬜ Another MNPS School
⬜ Private School
⬜ Out of County
⬜ Out of State
⬜ Virtual School
⬜ Home School
(please ✔ one)
⬜ Out of Country
⬜ Other: ___________________________________________________________________
Next Planned School of Enrollment:
__________________________________
School Name
________________________
City, State
Parent Comment: __________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
I understand and acknowledge that withdrawal from an MNPS Magnet/Optional/Charter School will result in forfeiture
of the student’s assignment at such school and that my student may not have the option to enroll in another MNPS
Magnet/Optional/Charter school until the next school year.
I understand and acknowledge that outstanding fees, fines, or unreturned school property such as textbooks, library
books, instruments, uniforms, or equipment may result in financial charges and/or withholding of student records.
Required - Attach Parent/Guardian Photo ID
____________________________
Parent/Guardian Phone #
Parent/Guardian Phone Call
⬜
______________________________________________
Parent/Guardian Name
______________________________________________
Parent/Guardian Signature
*************************************************************************************************
MNPS Use Only
Withdrawal Entered in SMS by _____________ W/D date _________ W/D code ______ Charter/Magnet Contacted: ___________
11/07/2014