Kimberly N. White, Ed.D.
Principal
Amy Gregory
Assistant Principal

WITHDRAWAL FORM

NAME:  ____________________  DATE OF WITHDRAWAL:  __________

TEACHER:  ____________________________ GRADE:  _____________

NAME OF NEW SCHOOL:  _______________________________________________

ADDRESS OF NEW SCHOOL: ____________________________________________

•	TEACHER:  All classroom books and materials have been returned.
Teacher:  ______________________________	
•	LIBRARY:  All books and materials checked out by this student have been      returned.
Librarian:  ______________________________	
•	LUNCHROOM MANAGER:  All lunch charges/refunds have been paid.
Lunchroom Manager:  ____________________
•	BOOKKEEPER:  All fees have been paid.
Bookkeeper:  _____________________
•	EXTENDED DAY:  All charges/refunds have been paid.
	Applicable	Not Applicable  	Extended Day Director:  _____________
•	ASSISTANT PRINCIPAL:  All PST documentation has been collected to send 
Applicable	 Not Applicable      Assistant Principal  _______________________

PRINCIPAL:  _________________________________________________

In compliance with Alabama Administrative Code 290-8-9-8(2)(e)2, special education and/or related services will be sent to the requesting school to which your child is transferring.  Instructional Support files will also be sent.  Please sign below indicating that you were made aware of this and given a copy.

Parent Signature:  ________________________   Date:  ______________

HOOVER
CITY SCHOOLS
HARRIETTE W. GWIN ELEMENTARY SCHOOL
1580 Patton Chapel Road o Hoover, Alabama 35226
205/439-2600
Fax 205/439-2601
Learning for Life