Republic of the Philippines
Department of Education
Region III
Division of Bulacan
Partida National High School
Partida, San Miguel, Bulacan
Dropping Out/Transfer of Students
S.Y. 2018-2019
Student Name: _____________________________________ LRN #: ___________________
Date of Birth: ________________ Grade: _______________________
Name of Parent/Guardian: ___________________________________________________________
Signature of Student: _______________________________________________________________
Parent/Guardian Signature: __________________________________________________________
Must have parent/guardian signature if under 18 years of age.
Address: _________________________________________________________________________
Reason for leaving: ________________________________________________________________
Transferring to: ____________________________________________________________________
Date of withdrawal: ___________________________ Parent’s Celphone #: ________________________
Subject Grade level Teacher’s initials
**Please indicate if there are any outstanding obligations and any other comments:_______________
________________________________________________________________________________
ELIZABETH I. CRUZ
Adviser’s Signature Date
ANDY G. TAYAMORA __________________________
Grade 7- Chairman’s Signature Date