MRHS Student Withdrawal Form

Required

Student Information

Student Namerequired

First Name

Last Name

Date of Birthrequired

Must contain a date in MM/DD/YYYY format

Graderequired

Student Addressrequired

Student Email Addressrequired

Student Phone Numberrequired

Parent/Caregiver Namerequired

First Name

Last Name

Parent/Caregiver Addressrequired

Parent/Caregiver Email Addressrequired

Parent/Caregiver Phone Numberrequired

Withdrawal Information

Date Submittedrequired

Must contain a date in MM/DD/YYYY format

Anticipated Withdrawal Daterequired

Must contain a date in MM/DD/YYYY format

Date of Last Attendancerequired

Must contain a date in MM/DD/YYYY format

Reason for Leavingrequired

Special Education Status (select all that apply)

Student has an active IEP and is receiving Special Education Services

Student has a 504 Plan

I have been informed of my rights as a student under Section 504 and the IDEA. I have been informed of all the services available to me.

Yes

I wish to have an evaluation in my suspected areas of disability

Yes

If no, I understand that should I wish to re-enroll, I can request an evaluation to determine eligibility for a 504 or special education services

Yes

Student Digital Signature (required if over 18)required

First Name

Last Name

Parent/Caregiver Digital Signaturerequired

First Name

Last Name

Thank you.

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