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3111 Fortune Way | Suite B-16 | Wellington | Florida | 33414
Toll Free: 1.800.890.6269 | Main: 561.537.5501 | Fax: 1.866.230.0259

Official Notice of Pupil Withdrawal
If you withdraw and you are on a payment plan, the entire tuition balance is due and payable immediately. No records will be issued or released
until the tuition balance has been paid.

Student Information
1. Student's Legal Last Name
2. Student's Legal First Name
3. Middle Name

4. Last day of attendance
5. Grade Level
6. Gender
7. Date of Birth


Male Female

/ /

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Are you seeking NCAA Initial Eligibility Requirements: Yes No
(Student athletes only)
8. Primary Withdrawal Type

Select the following that best describes why the student is withdrawing from school.

W1 Transfer to another school

W5 Dropout
W9 Transfer to be home taught W13 Financial Issues
W2 Illness

W6 Age

W10 Transfer to detention Other ______________
W3 Expelled or long term suspension
W7 Graduated
W4 Absence or status unknown
W8 Deceased
W12 Continuing studies at
vocational or technical school

9. Please note that you are still responsible for your student's balance of the tuition. If you have a outstanding financial balance, you will not be able
to attain any records from Forest Trail Academy. Please complete the section below to pay the balance.

Name on Card:

Pay In full$_____________

Credit Card Type:

Monthly Payments of $___________

Credit Card Number: ________-________-________-________ Date of each month to charge credit card

Expiration Date: ______/______ CVV: _________ ______ (MM)______(DD) _______(YY)

Billing Address:

Street Address




Zip Code

10. Parent/Guardian Signature
11. Date (MM/DD/YYYY)

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Note: If parent or guardian is unable to sign this form, the school district should indicate the reason the signature was not obtainable.

Form #: ADE-41-123, rev 5/2004; in compliance with ARS 15-827.

(c) 2007 Forest Trail Academy, LLC d/b/a Virtual High School of Excellence | Forest Trail Academy, LLC d/b/a Forest Trail Academy