SUGAR CREEK CHARTER SCHOOL: Student Withdrawal Form

To withdraw your student from Sugar Creek Charter School, the following form must be completed. This form notifies the registrar of your intent to withdraw your student and provides Sugar Creek Charter School the authorization to release student records to the transferring school.

Student Name (First and Last) *

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home Telephone # *

Cell Phone # *

K-8 Homeroom Teacher's Name

Student's Current Grade *

Reason(s) for leaving: (Please provide detailed explanation) *

Transferring School Information (For the transfer of student records.) *

Name of the School

School Address

City State / Province

Postal / Zip Code

School's Telephone Phone # *

School's Fax # *

Type of School *

Effective Date of Withdrawal *

Date

Parent/Guardian Signature *

Clear

Date *

Date

Government or State Issued Identification (Verify Signature) *

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