St. Anne-Pacelli Catholic School Official Withdrawal Form

Please allow 48 school hours to complete. Note: If your student has a school-issued Chromebook, it will be removed from our network and your student's school email address will be deactiviated.

Student Name Student Name First Last
Student's Grade Level
Current Address Current Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
New Address (if moving) New Address (if moving)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Requested Withdrawal Date Requested Withdrawal Date / MM / DD YYYY
Reason for withdrawal
*Entrance Date, Number of Days Present and Number of Days Absent to be completed by office

*Withdrawal Procedure (to be completed by office)
1. Principal Call/Meet with Parent/Guardian
2. Enrollment Team Notified
3. Guidance: Conf/Update PowerSchool
4. Athletic Dept. - Clear Y/N
5. Library - Lost/Damaged/Overdue
6. IT - Email removed/Chromebook deactivated
7. Textbooks all returned - Y/N
8. Cafeteria Clear - Y/N
9. Guidance: Locker Clear
10. Guidance: Contact parent/guardian (withdrawal info pickup)
11. Business Office - Account Clear Y/N
Grades
St. Anne-Pacelli Catholic School is on a semester system for the High School and a quarter system for the Lower School. You will receive, on the completed withdrawal form from the school, your student's grades for the last completed semester/quarter. Grades reflected will be the student's cumulative grade from the beginning of the current semester/quarter until the date of withdrawal.
I hereby authorize St. Anne-Pacelli Catholic School to release my child's school records and standardized test scores to any elementary school, middle school or high school, or post-secondary school that requires this information. I understand that all accounts must be paid in full, per Payment Policy, before any records, transcripts, grades, etc. are able to be released.

Parent/Guardian Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Signed Date Signed / MM / DD YYYY
Parent/Guardian Phone Number Parent/Guardian Phone Number - ### - ### ####
Parent/Guardian Email Address
Date Date / MM / DD YYYY