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5001c - Intent to Disenroll Form

West Point Public Schools


Student Name:            ____________________________

Requester’s Name:     ____________________________

Reason for Disenrollment (please also attach any documentation which supports the reasons for disenrollment, if applicable):


□  (A)   Financial hardship requiring the student to be employed to support the student’s family or a dependent(s) of the student.

□  (B)   Student’s illness which makes attendance impossible or impracticable.


Proof of legal or actual charge or control of the student (please also attach any documentation which proves legal or actual control of the student, if applicable): ________________________________________________________________________________________________________________________________________________________________________________


Upon receipt of this signed, written request for disenrollment, the superintendent or designee will set a time and place for an exit interview.  The following persons must attend the exit interview:

  1. The student, unless the student is too ill to attend;
  2. The person(s) with legal charge or control of the student who requested the interview;
  3. The superintendent or designee; and
  4. The student’s then-current principal or designee.


At the interview, the Requester must present the following evidence:

  1. The Requester has legal or actual charge or control of the student; and
  2. The student is disenrolling due to either reason (A) or (B) above


At the interview, the superintendent or designee must:

  1. Identify all known alternative educational opportunities, including vocational courses of study available to the student in the district; and
  2. Discuss how withdrawing from school is likely to reduce the potential future earnings for the student and increase the likelihood of the student being unemployed in the future.


At the conclusion of the interview, the Requester may either withdraw the request for disenrollment or sign the disenrollment form provided by the district.  The disenrollment form is different from the written request to disenroll, and it must include:

  1. The signature of the student, unless the student’s illness prevents attendance
  2. The signature of the superintendent or designee; and
  3. Acknowledgment from the superintendent or designee that
    1. The interview was held and the required information was presented;
    2. In the opinion of the superintendent or designee, the person making the written request has legal or actual charge or control of the child; and
    3. The child is in fact experiencing financial hardships requiring the child to be employed to support the child’s family or one or more of the child’s dependents, or the child’s illness makes it impossible or impracticable to attend.


By signing below, I understand that I am representing to West Point Public Schools that I am in legal or actual charge or control of the student.


For District Office Use Only:

Received By:                                      ____________                                On:                                         ___________

Placed in Student File on:             ____________                                Copy to Supt. on:                 ____________

Requester Signature: ____________________________________ Date:_____________

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