Withdrawal Notice

Please complete the following form to officially withdraw from Epic California Academy.

Name of Person Completing Form *

Email of Person Completing Form *

Parent and Student Information

Parent or Guardian Name *

Phone *

Email *

Student Name *

Grade Level *

Is the student moving to a new address? *

Yes

New Address *

Apt, suite, etc.

Country

City

State

Zip code

Withdrawal Information

Reason for Withdrawal *

If other, please elaborate. *

Name of Country *

Last Day of Enrollment at Epic California Academy *

Name and Address of New School

New School Name *

New School Address

Apt, suite, etc.

Country

City

State

Zip code

Special Education Services

Important

If the student being withdrawn is receiving Special Education services, please note the following and mark accordingly.

This student has

an active IEP and is receiving Special Education services.

a 504 Plan.

Other

Forwarding Records

Student educational records will be forwarded to the receiving school upon written request.

Additional Comments

Electronic Signature *

I verify that the information provided above is accurate

By electronically signing this document, I am attesting that all of the information I have provided is accurate and correct to the best of my knowledge and is intended to serve as my official signature. The Electronic Signatures in Global National Commerce Act, 15 U.S.C. § 7001, redefines a traditional signature as: (a) In General, Notwithstanding any statute, regulation, or other rule of law (other than this subchapter and subchapter II of this chapter), with respect to any transaction in or affecting interstate or foreign commerce-(1) a signature, contract, or other record relating to such transaction may not be denied legal effect, validity, or enforceability solely because electronic signature or electronic record was used in its formation.

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