Official Clearance for Transfer or Permanent Withdrawal

Student Name (First - Middle - Last):
Student grade:
Student date of birth: Student date of birth: / MM / DD YYYY
Student age:
SCH ID number:
STN number:
Name of parent / guardian:
Parent / guardian telephone: Parent / guardian telephone: - ### - ### ####
Parent / guardian address:
Local contact name:
Local contact phone number: Local contact phone number: - ### - ### ####
Will student be transferring to another country

Will student be transferring to another country Yes No
If yes, what country?
Withdrawal code:
I hereby attest that the above student is:

I hereby attest that the above student is: in good standing. “not in good standing” due to a current suspension and/or expulsion.
Name of new school:
Address of new school: Address of new school:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
I, the undersigned, do hereby give my permission/consent for (student name):
Name of Student Name of Student First Last
Name of Parent/Guardian (if student under 18): Name of Parent/Guardian (if student under 18): First Last
Date of Withdrawal: Date of Withdrawal: / MM / DD YYYY
Student will be attending (select one)

Student will be attending (select one) Homeschool located in Indiana If available, please attach the completed homeschool enrollment form found here: https://homeschool.doe.in.gov/HomeSchoolEnrollment.aspx Non-accredited nonpublic school located in Indiana This does not include career centers, job corps, High School Equivalency programs.
Homeschool Enrollment (Please copy and paste link in browwser)
Name of School:
Address of School: Address of School:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Notice of Legal Requirements of Attending a Non-Accredited Nonpublic School • Attendance Records: IC 20-33-2-20 requires a non-accredited nonpublic school, including homeschool, to maintain an accurate daily record of attendance to verify the enrollment and attendance of a student upon the request of the state superintendent or the public-school superintendent. There is no special form required for these attendance records. • Instruction: IC 20-33-2-27 & 28 provide that it is unlawful for a parent to fail, neglect, or refuse to send the parent’s child to a public school for a full term unless the child is being provided with instruction equivalent to that given in public schools. State law does not define “instruction equivalent to that given in public schools”. However, IC 20-33-2-12 provides that a non-accredited nonpublic school is not bound by any legal requirements set forth in IC 20 or IC 21 with regard to curriculum or the content of educational programs offered by the school. If there is ever a question of educational neglect, keeping good attendance records and other documentation regarding attendance and continuing educational activity is highly instrumental in addressing these concerns. The signatures below indicate that: • The parent acknowledges and understands the legal requirements of a non-accredited nonpublic school located in Indiana. • The parent acknowledges and understands the Indiana State Board of Education recognizes only high school diplomas conferred by schools that are accredited by the Indiana State Board of Education or a national accrediting body recognized by the Indiana State Board of Education. • The principal and parent acknowledge that if the parent/guardian refuses to sign this form, the student is considered a dropout, and the principal shall report the student to the BMV to revoke or refuse to issue a driver’s license or learner’s permit for the student.
Parent/Guardian Signature (student signature if student at least 18 years of age)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Principal’s Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Principal’s Signature Date Principal’s Signature Date / MM / DD YYYY