About this Form
Form number: 565-4a
Audience: School Staff
Last revised: June 2017
Form 565-4 - Student Permanent Withdrawal
Introduction: The purpose of the interview is to encourage the student to remain in their current/or other appropriate MCPS program. This interview is a counseling tool and an intervening process that may serve to enhance the student’s decision making. Additionally, it provides another means of reaffirming the school’s interest in the student and asserting the school’s continued willingness to be an ongoing resource to support the student. See MCPS Regulation JEC-RA, Student Withdrawals from Classes and School.
Directions: This form should be completed by the school counselor, pupil personnel worker (PPW), or a school administrator prior to completing MCPS Form 565-4,Student Permanent Withdrawal.
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