Withdrawal Form

Withdraw Form

Trumbull Career & Technical Center
Date

MonthDayYear
Date
Student ID
Last name
First name
Grade
Homeschool
Program
Program teacher email
example@example.com
Program Supervisor
Program Supervisor email
example@example.com
Program Secretary
Program Secretary email
example@example.com
Withdrawal date

MonthDayYear
Date
Counselor
Counselor email
example@example.com
IEP
EMIS reason for withdrawal
Surveyed reason(s) for withdrawal (check all that apply) Reasons indicated on the in-school survey will not appear on the final withdrawal record.
If enrolling in another school, list name of school
English teacher
English Email
example@example.com
Math teacher
Math Email
example@example.com
Government teacher
Goverment Email
example@example.com
Science teacher
Science Email
example@example.com
The student is eligible for a refund or owes money for the following reasons

Other
Comments
How did the guardian notify TCTC?
Supporting document from guardian

Copy of email, notes, etc. from guardian
Cancelof
Conference outcomes
Grade verification sheet, other documents related to withdrawal

Cancelof
This withdrawal form is ready for the next steps, and the above fields are ready to be locked.
Program Teacher

This section is for Program teacher only.
Program percentage
Enter Student grade percentage
Program materials returned
Program list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
English Teacher

This section is for English teacher only.
English percentage
Enter Student grade percentage
English materials returned
English list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
Government Teacher

This section is for Government teacher only.
Government percentage
Enter Student grade percentage
Government materials returned
Government list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
Math Teacher

This section is for Math teacher only.
Math percentage
Enter Student grade percentage
Math materials returned
Math list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
Science Teacher

This section is for Science teacher only.
Science percentage
Enter Student grade percentage
Science materials returned
Science list of all items not returned
Please provide the quantity, price, and description of each item that has not been returned.
iPad Return

Please mark yes/no if all items have been returned.
Apple iPad
Apple iPad cost
Power brick
Power brick cost
Charging cord
Charging cord cost
Case
Case cost
Apple MacBook

Please mark yes/no if all items have been returned.
Apple MacBook
Apple MacBook cost
Power brick
Power brick cost
Charging cord
Charging cord cost
Device carrying case/bag
Device carrying case/bag cost
Mobile Wifi hotspot

Please mark yes/no if all items have been returned.
Hotspot returned
If student was not issued a hotspot please select N/A.
Mobile wifi hotspot cost
Media Center

Please mark yes/no if all items have been returned.
Media Center materials have been returned
If student was not issued materials please select N/A.
Materials description
Total material cost
Secretary
I the Program Secretary have reviewed all of the information is correct and completed. This form is ready for Supervisor review.
Item 1
Price of item 1
Item 2
Price of item 2
Item 3
Price of item 3
Item 4
Price of item 4
Item 5
Price of item 5
Item 6
Price of item 6
Item 7
Price of item 7
Item 8
Price of item 8
Item 9
Price of item 9
Item 10
Price of item 10
Total amount due of listed items
Should be Empty:

Withdraw Form

Program Teacher

English Teacher

Government Teacher

Math Teacher

Science Teacher

iPad Return

Apple MacBook

Mobile Wifi hotspot

Media Center

Secretary