Student Withdrawal Form
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*
Required
THIS SECTION MUST BE COMPLETED BY THE PARENT/GUARDIAN.
Student Name
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required
First Name
Middle (optional)
Last Name
Date of Birth
*
required
Must contain a date in MM/DD/YYYY format
Student Address
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required
Current School
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required
Early Childhood Center at B.P. Mission
Winthrop STEM Elementary Magnet School
Nathan Hale Arts Magnet School
Bennie Dover Jackson Multi-Magnet Middle School Campus
New London High School Multi-Magnet Campus
Current Grade Level
*
required
PreK
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Select one from the dropdown menu.
Student's Last Date of Attendance
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required
Must contain a date in MM/DD/YYYY format
New School Name
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required
Must contain only letters and spaces
New School Address
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required
Parent/Guardian Phone Number
*
required
The phone number entered could not be formatted, but will still be saved upon submission.
Parent/Guardian Email Address
Agreement
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required
I am aware and authorize copies of student records (may include grades, standardized test scores, discipline, attendance, immunization, special education, and personal history records) to be forwarded to requesting schools and/or authorized individuals or institutions. I also understand that all books and supplies belonging to New London Public Schools must be returned before transcripts/report cards are released.
Parent/Guardian Name
*
required
First Name
Last Name
Suffix (optional)
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