Student's Name *

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Withdrawal Date *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reason for Withdrawal *

Transfer to Public School

Transfer to Private School

Transfer to another Homeschool Program

Other

New School Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

New School Telephone *

(###)

###

####

Tuition Payment Agreement *

I will pay any remainder tuition payments based on my semester to semester commitment (August to December and January to May) from on my agreement made at enrollment.

Date *

MM

DD

YYYY