[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

Please send records to: (name and address of NEW SCHOOL - records can not be sent to parents)

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

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).

Click Here to Upload

Decree of Guardianship (if applicable)

Click Here to Upload

FOR SCHOOL USE ONLY

Guidance Interview:

___ Yes ___No

Guidance Signature

Administration Interview:

___ Yes ___No

Administration Signature