Student Drop Out Form

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Republic of the Philippines

Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OF PAMPANGA PROVINCE
PULUNG SANTOL NATIONAL HIGH SCHOOL
PUROK 3 PULUNG SANTOL, PORAC, PAMPANGA

STUDENT DROP-OUT FORM


(For SHS Students)

Last Name First Name Middle Initial

Grade Level Track/Strand Section

Please Check Reason/s for Dropping Out:

☐ Family problems ☐ Employment


☐ Financial reasons ☐ Pregnancy/Medical concerns
☐ Inability to cope with studies ☐ Transfer to ALS Program
☐ Loss of interest in studying ☐ Others: __________________________

To be completed by Parent/Guardian of student below 18 years of age:

I am aware and support my child’s withdrawal from his current enrolment for
the grade level and year indicated above. I understand all the implications and
consequences of withdrawing my child’s enrolment.

________________________________ ________________________
Signature over Printed Name Date

________________________________ ________________________
Adviser’s Name and Signature Date Received

Address: Purok 3 Pulung Santol, Porac, Pampanga


Telephone No.: (045) 649-4839
Email Address: psnhs1983@gmail.com

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