JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Pre-K/EC Student Withdrawal Form
This form needs to be completed when a student is no longer attending.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Reason for completing this form:
*
Complete withdrawal from program
Placement change
Discontinued services
Other:
Student's Full Name
*
Last, First, Middle
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
SIS Number of student (this is a nine digit state ID - it should be listed in student information system of school)
*
Your answer
Building attended
*
Choose
Never enrolled in Pre-K/EC
Johnston City
Marion- Jefferson
Marion- Adams
Crab Orchard
Herrin
Carterville
Session attended
*
Choose
Morning
Afternoon
n/a
Does the student have an IEP?
*
No IEP
IEP- Speech only
Full IEP
IEP- Walk in speech
Date Dropped
*
Be sure that drop date is consistent with the school secretary.
MM
/
DD
/
YYYY
Reason for withdrawal
*
Choose
Moved within Williamson County
Moved outside of Williamson County
To attend a full day program
Transportation issues
Other
If reason for withdrawal is not listed or you know the name of the program the child is now attending, please explain
*
If moving to different program within the district, please state that information (ex. transfer from Ragan AM to Keel AM)
Your answer
Person completing this form
*
First and last name
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Williamson County Education Services.
Report Abuse
Forms
