Portal

Student Withdrawal Notice

Parent/Legal Guardian signature/ Student over 18 years old *

Name of Parent/Legal Guardian/Student over 18 *

STUDENT INFORMATION

Middle Initial

ACKNOWLEDGEMENT

Date*

Relationship to Student *

Please verify your answers. After pressing SUBMIT FORM, if there are errors, they will be noted in red.

Last Name*

First Name*

Date of Birth*

Last Date of Attendance*

School From Which Student Is Withdrawing:*

Other:*

(Note: School-age students must be enrolled in an academic setting.)

Name of New School:

Reason For Withdrawal:*

Other:

The answer you give below will help the district determine what services you or your child(ren) may be able to receive under the McKinney-Vento Act. Your answer will be kept confidential and will only be shared with those staff responsible for providing services to the student and keeping track of how many students are identified as living in temporary housing. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

In a shelter

With another family or other person because of loss of housing or as a result of economic hardship

In a hotel/motel

In a car, park, bus, train, or campsite

Other temporary living situation (please describe):

In permanent housing

Where is the student currently living? (Please select one ) *

(sometimes referred to as "doubled up")

Upon request, personnel from the Ithaca City School District will provide academic records and related school documents to the student’s new school. By signing below, the parent, guardian, or adult student acknowledges their permission for release of said documents.

400 Lake Street • P.O. Box 549 • Ithaca, New York • 14851-0549

ITHACA CITY SCHOOL DISTRICT

NEW SCHOOL INFORMATION

Registration/Enrollment Date:

Address:

City:

St:

Zip:

Phone:

Fax:

Registrar Name:

All Ithaca City School District issued devices and/or borrowed materials must be returned. This includes textbooks, sheet music, uniforms, musical instruments, cameras, calculators, phys.ed. locker lock, library books, or anything else the student has borrowed.

Acknowledged*

(Use mouse to sign)

OFFICE USE ONLY

Student ID: