The College Prep and Leadership Academy

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Student Withdrawal Form

Last Date of Attendance*

Student Name*

Student Address*

Current Grade*

New School*

School Address

School Phone*( ) -

Fax( ) -

Is the new school*

Public

Private

Other

If you chose other please explain

Reason for withdrawl*

Relocated

Other

If you chose other please explain

Records Release

I hearby authorize full and complete disclosure of the above named student's full cumulative records to any school upon their request.

Signature*

Your typed name here serves as an electronic signature.

Current Date*

Notice*

I understand that, in order for the withdrawal process from CPLA to be completed, all books, electronics, and any fees owed will need to be settled in full.

Please leave this field blank.