This is the LAKE VIRTUAL School Withdrawal Form only. Please do not use this form for other schools or homeschool.

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Completion/Submission of this form certifies that all the information on each page of this withdrawal form is true to the best of my knowledge and belief.
F.S. 837.06 False official statements Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in § 775.082, Fla. Stat, § 775.083, Fla. Stat.

Student's Last Name *

Student's Legal Last Name as listed on the student's birth certificate.

Student's First Name *

Student's Legal First Name as listed on the student's birth certificate.

Student's Middle Name

Student's Legal Middle Name as listed on the student's birth certificate.

Student's Date of Birth *

YYYY

Student's Current Grade *

Student's School ID Number (if known)

Primary Parent/Guardian (Student) Current Address *

Street, City, State, Zip

Primary Parent/Guardian Name *

Legal name as it appears on the Driver's Licence. Parent/guardian MUST be on the student's record as the LEGAL/PRIMARY parent/guardian.

Primary Parent/Guardian Preferred Contact Number *

Please pick one:

The above student is withdrawing to another school, a virtual program, or homeschool program.

The above student is withdrawing and does NOT plan on continuing their education.

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