Learner Withdrawal Form

Learner Information

Learner First Name *

Learner Last Name *

Date of Birth *

Learner Address *

Learner City *

Learner State *

Learner Zip *

Special Education *

This learner does not receive Special Education services.

This learner has an active IEP and is receiving Special Education services.

This student has a 504 plan.

EF Information

Educational Facilitator First Name *

Educational Facilitator Last Name *

Educational Facilitator Email *

A copy of this form will be sent to your EF upon submission.

Parent Information

Parent/Guardian Phone *

Parent/Guardian Email *

General Information

Reason for Withdrawal

Please share any feedback on iLEAD Exploration below.

Note

If you are withdrawing and filing a Private School Affidavit (PSA) to homeschool, please submit a copy of your PSA to enrollment@ileadexploration.org.

New School *

Enter new school name and address here.

This withdrawal form is not a record request. Student educational records are not forwarded to the new school until a formal written or faxed request from the new school is received by the iLEAD’s enrollment department.

The formal record request can be faxed to 657-231-8223, emailed to enrollment@ileadexploration.org or mailed to:

iLEAD Exploration
Attn: Registrar
2973 Harbor Blvd #616
Costa Mesa, CA 92626

Parent/Guardian Name *

Type full name in box

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