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Student Withdrawal Form
Requests for Student Withdrawal by Authorized Parent/Guardian
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* Indicates required question
Email
*
Your email
Date of Request
*
MM
/
DD
/
YYYY
STUDENT First Name
*
Your answer
STUDENT Last Name
*
Your answer
STUDENT Current Grade
*
Choose
Grade 9
Grade 10
Grade 11
Grade 12
EFFECTIVE DATE of Withdrawal
*
Please Choose the Date That Will Be (or Was) Your Student's Last Day at Imhotep
MM
/
DD
/
YYYY
REASON for Withdrawal
*
Your answer
PARENT/GUARDIAN Name
*
Your answer
PARENT/GUARDIAN Email Address (Must be the Email Address on Record)
*
Your answer
DESTINATION School
*
If You Already Know Your Student's Future School, Please Let Us Know
Your answer
Do You Have SCHOOL MATERIALS/EQUIPMENT That Need To Be Returned to Imhotep? (i.e. School Laptop and Charger)
PLEASE NOTE THAT IMHOTEP WILL NOT RELEASE RECORDS OF STUDENTS THAT HAVE NOT RETURNED SCHOOL EQUIPMENT
Yes
No
Other:
Clear selection
STUDENT RECORDS
PLEASE NOTE THAT YOUR STUDENT'S NEW SCHOOL MUST SEND A RECORDS REQUEST FOR YOUR STUDENT'S RECORDS. IF YOU WOULD LIKE A COPY, PLEASE SELECT HOW YOU WANT TO RECEIVE THEM
Mail
Email
Pick Up From School
Other:
Clear selection
Electronic Signature for Authorization (Type Your Full Name)
*
By Submitting My Name Here I Certify That I Am A Parent/Guardian of The Student That Is Listed On The Student's Enrollment Documents.
Your answer
Phone Number for Verification
*
Please List the Telephone Number Where We Contact You to Verify The Changes Requested
Your answer
A copy of your responses will be emailed to the address you provided.
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