Student Withdrawal Form

Mercer Island High School

9100 SE 42nd • Mercer Island, WA 98040

Student Legal Name: _____________________________________________ Birthdate: _______________________

Mercer Island School: _______________________________________________ Grade: _______________________

I am withdrawing this student for the following reason(s): _________________________________________________

________________________________________________________________________________________________

Contact Phone #: __________________________________________________________________________________

Forwarding Address: _______________________________________________________________________________

Last Date of Attendance: ____________________________________________________________________________

New School: _____________________________________________________________________________________

New School Address: ______________________________________________________________________________

New School's Phone: ______________________________________________________________________________

Type of School: _____ Public _____ Private _____ Home School _____ Other

_________________________________________________________________________________________________________

Parent/Guardian Signature Student Signature (if over 18)

Secondary Students Only

Period Subject Grade Books returned Teacher Signature

at Withdrawal Fees or Fines

___________________________________________________________________________________________________________

1

2

3

4

5

6

7

Registrar Date Withdrawal Code

Food Service

Library

Bookroom

ASB

Attendance

Locker

iPad

JW/vaPublishingCenter/HS Student Withdrawal/Dist. Items Storage/4-9-13

Please take the withdrawal form to teachers. Teachers/Support Staff must complete this section.

Outstanding fees will result in ofcial transcripts being held until nes are cleared.