Exit Information
This is an online survey ONLY, NOT AN OFFICIAL WITHDRAWAL FORM.

This form is used to gather information concerning the withdrawal of a PALCS student. Once this online form is completed a PALCS representative will send you an official Withdrawal Form for your signature via DocuSign. Once you receive the DocuSign, please complete ASAP in order to have your students withdrawal from PALCS finalized.

*Please note, if you are withdrawing more than one student, a separate Exit Form needs to be completed for EACH student. You will then receive a separate DocuSign for each student that is being withdrawn.
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Email *
Last name of withdrawing student *
If more than one student is being withdrawn, please complete a separate Exit Form for EACH student.
First name of withdrawing student *
If more than one student is being withdrawn, please complete a separate Exit Form for EACH student.
Current Grade of student: *
Does this student participate in PALCS USP or CPFA program(s)? *
Required
Name of parent or guardian filling out this form: *
New School Name *
Please list the specific name of the school to which the student is transferring.
What is the first day of attendance at the new school? *
MM
/
DD
/
YYYY
Reason for Withdrawal:
PALCS would like to learn how we could have served you better. Please briefly explain the reason for withdrawal.
What is the best phone number to reach you at in regards to this withdrawal?
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