Withdrawal Form
Firelands Local School District
112 N. Lake St.
South Amherst, OH 44001

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Email *
Student's Last Name *
Student's First *
Student's Grade: *
Student's Current Address (include city): *
Student's New Address (if applicable)(include city, state, and zip code):
Student's Birth Date: *
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DD
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Parent/Guardian's Name: *
Parent/Guardian's Name(If applicable):
Parent/Guardian's Contact Phone Number: *
Student's Withdraw Date: *
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/
DD
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YYYY
Reason for Withdrawal: *
Student's New School/School District:
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