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Withdrawal Notice
Please complete the following form to officially withdraw from Epic California Academy.
Name of Person Completing Form *
(Required)
Email of Person Completing Form *
(Required)
Parent/Guardian and Student Information
Parent or Guardian Name
(Required)
Phone
(Required)
Email
(Required)
Student Name
(Required)
Grade Level
(Required)
TK
K
1
2
3
4
5
6
7
8
9
10
11
12
Is the student moving to a new address?
(Required)
Yes
No
New Address
(Required)
Street Address
Withdrawal Information
Reason for Withdrawal
(Required)
Transfer to another public school in your county
Transfer to a private school
Transfer to another California school
Transfer out of state
Transfer out of the United States
Home School
Other
Country
(Required)
Please explain
(Required)
Last Day of Enrollment at Epic California Academy
(Required)
MM slash DD slash YYYY
New School Information
New School Name
(Required)
New School Address
(Required)
Street Address
Special Education Services
If the student being withdrawn is receiving Special Education services, please note the following and mark accordingly.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
Additional Comments
Forwarding Records
Student educational records will be forwarded to the receiving school upon
request
.
Electronic Signature
(Required)
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.
I verify that the information provided above is accurate
CAPTCHA
