Instructions for Withdrawal from Attendance Form 10-005
This form is to be utilized by the superintendent or designee of the superintendent for a public school district. All of the required fields in the form must be entered before the form can be printed. The form will alert you if a required field has not been entered. Only one of the two boxes for the reason for withdrawal of the child on the form can be entered.
The form is only to be completed if:
- The person making the written request does not rescind that request at the end of the exit interview; and
- The superintendent or designee believes that a preponderance of evidence has been presented by the person making the request that (a) the person has legal or actual charge or control of the child, and (b) the child is experiencing (i) financial hardships requiring the child to be employed to support the child’s family or dependents of the child, or (ii) illness that makes attendance impossible or impracticable.
If superintendent or designee determine these conditions exist at the close of the exit interview, then the person making the request and the superintendent or designee are required to sign the form. The child shall sign the form if the child is experiencing financial hardships requiring the child to be employed to support the child’s family or dependents of the child.
A copy of the signed form should be provided to the person making the request, with a copy also being placed in the student’s file of the school district under Section 79-2,104.
The school district is required to provide the Nebraska Department of Education with a copy of withdrawal forms which can be accomplished by sending a PDF of the completed form with signatures via e-mail to email@example.com.