Withdrawal Form

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Withdrawal Form

Email *

Student Name *

Grade Level *

Requested effective withdrawal date *

YYYY

Reason for withdrawing *

Transferring school - where will the student be enrolled after leaving DA (includes Homeschool)? *

What date will the student begin attending the new school? *

Please confirm you have reviewed DA's withdrawal policy. *

Parents wishing to withdraw students from school must complete this withdrawal form. Students will be considered still enrolled in the school until the withdrawal form is filled out properly and turned into the office. Unless withdrawal is due to an emergency or to special circumstances, the following prorated tuition refund schedule (does not apply to EdChoice):

1. Withdrawal by the end of week one or two – 100% refund 2. Withdrawal by the end of week three – 80% refund 3. Withdrawal by the end of week four – 60% refund. 4. Withdrawal by the end of week five – 40% refund.

5. Withdrawal by the end of week six – 20% refund. 6. Students withdrawing from a course after the sixth week of the semester will be charged full tuition for the remainder of that semester for each course. Students withdrawing from academic classes after the end of week six of the semester, will receive Withdraw/Passing(W/P) or Withdraw/Failing (W/F) on their transcripts.

I have read and understand the school's withdrawal policy.

Required

Please print parent /guardian name. *

Phone number *

Please add your initials here to confirm and submit this form to withdraw your student from Dominion Academy. *

Academic Director Signature

Head of School Signature

A copy of your responses will be emailed to the address you provided.

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