Student Withdrawal Form Elite Open School
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1Student Withdrawal Form
Please submit the completed form by e‐mail, mail, or fax. Our e‐mail address, mailing address, and fax number are
shown below. If you have any questions or concerns, please call us at: 909‐444‐5587.
E-Mail Address:
Mailing Address:
19735 Colima Rd # 2
Rowland Heights, CA 91748, USA
Name of student: ___________________________________________________ Grade: _________________
Last date of attendance: _______________________________________________________________________
Reason for withdrawal: ________________________________________________________________________
Forwarding address: __________________________________________________________________________
___________________________________________________________________________________________
Parent/Guardian e‐mail address: ________________________________________________________________
Records to be sent directly to new school: Y / N Hand carried: Y / N
Name of School: _____________________________________________________________________________
Address: ___________________________________________________________________________________
__________________________________________________________________________________________
School E‐mail Address: ________________________________________________________________________
Parent Certification:
It is my intention to withdraw the above named student on the indicated date from Elite Open School. I understand that
none of my child’s academic or social records will be surrendered or sent to me or the next school at which my child may
enroll if there are any outstanding debts owed to EOS, including: tuition fees, library fines and cost of books, materials and
supplies that my child may have lost or damaged.
Parent /Guardian Signature: ___________________________________ Date: ____________________________
OFFICE USE ONLY
Date Received:
Date Sent/Initials:
, Rowland Heights, CA 91748 USA 909‐444‐5587
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