CHS WITHDRAWAL FORM
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Date *
MM
/
DD
/
YYYY
Student Name *
Date of Birth *
MM
/
DD
/
YYYY
Current Grade *
Student Athlete *
NJROTC *
Student Activities - Please check all that apply *
Required
Please select a reason for withdrawal *
If none of the Reasons for Withdrawal above apply, please describe your reason for withdrawal
Name of new school *
New school address *
New student address *
Parent/Legal Guardian Name *
Home Phone Number *
Cell Phone Number *
Work Phone Number *
Email Address *
Electronic Parent Signature - By signing this form, you agree that you are the parent/legal guardian of the student being withdrawn and that the information contained in this form is accurate *
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