Parent Assurance Form

Please complete the form below. Required fields marked with an asterisk *

Student Name*

Answer Required

Date*

Answer Required

Student Date of Birth*

Answer Required

Student Grade*

Answer Required

TK/ Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

Please check the box:*

Answer Required

I declare that I am the parent/guardian/caregiver of the student named above and I am withdrawing them from this school due to the following reason below:

Please select reason for disenrollment below:*

Answer Required

Enrolling in another public school (please provide school name below)

Enrolling in a private school (please provide school name below)

Moving to another city within the State of California (please specify information below)

Moving to another state (please specify state and city below)

Moving to another country (please specify country below)

Full-time private tutoring by a credentialed tutor

Other:

I assure you that I will enroll this child in a school within a reasonable period of time. I am aware of the compulsory education statute in California, as stated in Cal. Education Code Section 48200 that requires all children between the ages of 6-18 years old to have a full-time education, unless they are exempt. I also understand that if I fail to compel the attendance of the child in my care to attend a full-time education while in the State of California, unless they are exempt, that I may be subject to criminal penalities.

To the best of my knowledge, this child will be attending school in the city and state of:*

Answer Required

I declare under penalty of perjury under the laws of California that the above statements are true and correct.

Signature*

Signature Required

New Address

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Please fix the highlighted areas below before submitting.

Parent Assurance Form