Plano Independent School District Attn: Student Records Department 2700 W. 15th Street Plano, TX 75075

INTENT TO WITHDRAW I am withdrawing my child from the Plano Independent School District for the reason listed below. I am the legal guardian of this student. I plan to enroll him/her in the school named below on or about the date indicated. Student Name:

____________________________________________________________

Grade Level:

____________________

Expected Date of Withdrawal from Plano ISD:

Student ID #:

__________________

____________________________________

Name of Plano ISD School: ______________________________________________________ Withdrawal Reason: ____________________________________________________________

Expected Date of Enrollment at Next School:

____________________________________

Name and Address of Next School: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ If withdrawing to attend College in an academic program, indicate whether you will be a full time student enrolled in at least 9 hours: ________Yes _________No If moving, please provide a forwarding address if known: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

_______________________________________________ Printed Name of Parent or Legal Guardian

________________________ Relationship

_______________________________________________ Signature of Parent or Legal Guardian

________________________ Date

_______________________________________________ Signature of School Administrator/Title

________________________ Date

(PISD school records will be sent upon request from next school.) Student Records Form SR-L02 01-29-2010

Clark High School 523 W. Spring Creek Pkwy. Plano, TX 75023

INTENTO DE RETIRAR Yo estoy retirando mi hijo/a de las escuelas del Distrito de Plano por la razon nombrado abajo. Yo soy el guardian legal de este estudiante. Yo voy a inscriber el/ella en la escuela nombrada abajo en la fecha indicada. Nombre del estudiante: __________________________________________________________ Grado:

____________________

Frecha de retararse de Plano ISD:

#de ID del Estudiante:

__________________

____________________________________

Nombro de su escuela en Plano: ___________________________________________________ Razon de retirarse:

____________________________________________________________

Fecha de inscribirse en su proxima escuela: ____________________________________ Nombre y direccion de la escuela: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Si estan cambiando de damicilio, favor de poner su nueva direccion: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

_______________________________________________ Nombre de Padre o Guardian Relacion

________________________ al estudiante

_______________________________________________ Firma de Padre o Guardian Fecha

________________________

_______________________________________________ Frima de Administrador de la escuela/Titulo Fecha

________________________

(PISD school records will be sent upon request from next school.) Student Records Form SR-L02 3-20-03