Withdrawal Notification

Food Service

ID number:

Student Name:

Grade: Homeroom:

Withdrawal date:

Student food service debit:

(Student owes school district)

Student food service credit:

(District owes student)

1. Form to be completed by office when student withdraws

2. Send form to building cafeteria

3. Cafeteria completes the debit/credit information and returns to office

4. Office assesses fee to student OR creates requisition for reimbursement

5. Email requisition to District Food Service Department for signature