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