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CCA Withdrawal Form
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Email *
Student 1 Full Name and Current Grade Level *
Student 2 Full Name and Current Grade Level
Student 3 Full Name and Current Grade Level
Student 4 Full Name and Current Grade Level
Please list your child(ren)'s homeroom teacher(s). *
Effective Date *
MM
/
DD
/
YYYY
New School
Please provide this information for student cumulative file/record transfer. 
 *
New School Full Address *
Why did your family choose to leave CCA? *
Parent/Guardian 1 Full Name *
Parent/ Guardian 1 Email *
Parent/ Guardian 1 Phone Number *
Parent/Guardian 2 Full Name
Parent/ Guardian 2 Email
Parent/ Guardian 2 Phone Number
By typing my name below, I understand that once my student withdraws, my student cannot be re-admitted unless I complete another Wait List Application. I understand that my student's name will move to the bottom of the wait list. *
A copy of your responses will be emailed to the address you provided.
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