[City of Bristol CT] Withdrawal Form

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Student Withdrawal Form

Student's First Name

Student's Middle Name

Student's Last Name

Student's Grade

Which school does student attended in Bristol?

School Counselor

Parent/ Guardian's primary phone number

Parent's Email Address

I, the undersigned, parent/guardian/eligible student* hereby request the withdrawal of my son/daughter from school for the reason checked below. I further authorize the release of all educational, special education and heath records to the school/program indicated on this form. (*only students age 18 or older are eligible to withdraw themselves from school).

Reason for withdrawal

Other Reason not listed above

What is the name and address of the NEW SCHOOL your child will be attending? Records will be sent to them after Bristol Public Schools receives a "request for records" from them.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Parent's picture identification (examples below)

current driver's license
current State of CT issued ID
current passport
current Permanent Resident Alien Card

Upload ONE Parent / Guardian / Eligible Student identification* from list above (*only student age 18 or olders are eligible to withdraw themselves from school).

Decree of Guardianship (if applicable)

FOR SCHOOL USE ONLY

Guidance Interview:

___ Yes ___No

Guidance Signature

Administration Interview:

___ Yes ___No

Administration Signature

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Student Withdrawal Form

Student's Date of Birth

Name of Parent / Guardian withdrawing student

Forwarding Address (if family is moving to another town, state, or country)

Date of Withdrawal (last day of school)

When was (will be) the Bristol Public School's device provided to the student returned?

When was (will be) the Bristol Public School's textbooks, library books, athletic uniforms, etc. returned?

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Today's Date

Upload ONE Parent / Guardian / Eligible Student identification* from list above (*only student age 18 or olders are eligible to withdraw themselves from school).

Decree of Guardianship (if applicable)

EXIT SURVEY - If withdrawing/transferring for any reason other than moving, please check off all that apply