UISD Withdrawal Procedural Manual - United Independent School ...

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Student Withdrawal / Record Transfer FormDistrict Name :United Independent School DistrictSchool Address:3707 Ave Los PresidentesSchool Number:USMSLaredo, TX 78046School Name:043 -United South Middle SchoolSchool Phone:(956) 473-7700School Fax:(956) 473-7799Student InformationLegal NameDemographicsID NumbersFirst: JoseDate of Birth09/07/1998Student DOE#:Middle:MariaSex:MPrior Student ID:Last: CantuGrade Level: 07Student Local ID: 100033Enrollment InformationEntry Date School Grade Level Withdrawal Date08/25/2011 043 -United South Middle School 0608/27/2012 043 -United South Middle School 07 08/27/2012Immunization InformationExemption Code:DiphtheriaImmunizationDate ReceivedDiphtheria Immunization 07/26/1999 01/20/2000 10/17/2000 10/15/2001 10/08/2002 08/23/2011Haemophilus influenzae type b 07/26/1999 01/20/2000 10/17/2000ImmunizationHepatitis A Immunization 11/29/2000 10/15/2001Hepatitis B Immunization 09/07/1998 07/26/1999 10/17/2000Measles Immunization 01/20/2000 10/08/2002Meningococcal Immunization 08/23/2011Mumps Immunization 01/20/2000 10/08/2002Pertussis Immunization 07/26/1999 01/20/2000 10/17/2000 10/15/2001 10/08/2002 08/23/2011Poliomyelitis Immunization 07/26/1999 01/20/2000 10/17/2000 10/08/2002Rubella Immunization 01/20/2000 10/08/2002Tetanus Immunization 07/26/1999 01/20/2000 10/17/2000 10/15/2001 10/08/2002 08/23/2011Varicella Immunization 10/17/2000 11/10/2008Date Received Date Received Date Received Date Received Date Received Date Received(Principal)(Counselor)Records Requestor (Please Circle)District / Parent / Guardian / StudentDistrict Name (if requestor)(Registrar)Withdrawal Reason:Returned to HomeCountryI, am requesting this information for enrollment in :(City, State or District)Retain this form for enrollment in your school. This form is necessary for enrollment.Student Withdrawal / Record Transfer Form11/12/2012 10:15:15 AM
UNITED INDEPENDENT SCHOOL DISTRICTOffice of Admissions~Attendance~Dropout RecoveryEnrollment Verification FormFROM: United Independent School District Campus:Person sending request: Phone: Fax No:Email:@unitedisd.orgTO: CAMPUS REGISTRAR/ADMINISTRATORDistrict: ___________________________________ Campus: ______________________________________Fax No: __________________________________CITY/STATE: ____________________________________Email:____________________________________________________Please verify that the student named below is enrolled at your school. To be filled by receiving campus/district.Student:PEIMS#(Texas only)Date of Birth:Grade:_____ NO, student has never enrolled at our campus_____ YES, the student is enrolled on our campus as of (Date)____________________________________ YES, the student was enrolled on our campus, but has since withdrawn.Date of Entry: ___________________________________________Date of Withdrawal: _____________________________________Name of School student withdrew to: _____________________________________District: ___________________City/State_________________________Verified by: _____________________________________________________________Title: ________________________________ Date: _______________________Campus/District__________________________________________________________Please fax or email a copy of this document to the person requesting the student information.We appreciate your assistance.UISD FORM 882-006Revised July 2012
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UISD Withdrawal Procedural Manual - United Independent School ...

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