Virtual Learning Services Removal Form
Student Information
Student Name:
Last
First
MI
Address:
M:
F:
Date of Birth:
Parent/Guardian:
Last
Phone:
First
H:
W:
MI
C:
School Name:
Grade:
Please mark the specialized services your child receives:
____Gifted
____ESOL
____IEP
Reasons for Removal from Virtual Learning
1)
2)
3)
4)
Parent/Guardian Agreement/Release for Information
I am requesting that my child be removed from the Virtual Learning services program to enroll in the
Traditional instructional setting. I understand that the change may take several days/weeks to process the
request. I also understand that my student's grade in Edgenuity will transfer into their in-person class.
Parent/Guardian Printed Name
Date
Parent/Guardian Signature
Date
School Use Only:
Principal Signature:
PowerSchool Change Completed by :
Teachers Notified of the Change by:
Comments:
Date
Date
Date