Withdrawal Notice – EPIC California

Parent or Guardian Name * First Last

Phone *

Email *

Student Name * First Last

Sex *

MaleFemale

Grade Level *

Is the student moving to a new address? *

YesNo

New Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Reason for Withdrawal *

If other, please elaborate. *

Name of Country *

Last Day of Enrollment at Epic Charter School *

New School Name *

New School Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Important If the student being withdrawn is receiving Special Education services, please note the following and mark accordingly.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

Forwarding Records Student educational records will be forwarded to the receiving school upon written request.
Additional Comments
Electronic Signature *
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