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      Internet Home School
          3060 Hozoni Rd
            Prescott, AZ 86305

STUDENT WITHDRAW FORM

We must receive the withdraw form 30 days before your next bill date in order to avoid continuing charges on your credit card or checking account.

In order for us to complete the withdraw process and have the necessary transcripts and report cards finalized. We need the following:
        1. Completed school work (Sent to the Prescott Office).
        2. All quarterly exams completed.
        3. Textbook sent to: Internet Home School 3060 Hozoni Rd Prescott, AZ 86305

WE MUST RECEIVE THE WITHDRAW FORM TO DISCONTINUE SERVICE.

Instructions:

Please note the following:

(1) After completing this form, fax or mail it to 3060 Hozoni Rd Prescott, AZ 86305 --- fax number: (928)708-9384

(2) Withholding grades Policy: Report card, Diplomas and transcripts will be held for unpaid fees . We will also hold
grades if you have not returned the textbooks.

(3) In accordance with the compulsory attendance laws of your home state, notice of your withdrawal from Internet Home School will be forwarded to the local Independent School district within 30 days.

(4) A 30 day advanced notice using this form must be submitted to suspend billing.

Internet Home School
3060 Hozoni Rd.
Prescott, AZ 86305

STUDENT WITHDRAWAL FORM

Student Name: __________________________________________________________________

Student ID Number: ______________ Student's Social Security Number____________________

Date of Enrollment_____________ Date of Withdrawal:______________

Telephone No: _________________ Parents E Mail Address:__________________

DATE WITHDRAWAL IS TO BE EFFECTIVE 30 DAY'S AFTER RECEIPT OF THIS FORM

_______________________________

Reason for withdraw:_________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Parent or Guardian Signature__________________________________________________

--Do Not Fill In Information Below This Line. For office use only.--

Checklist for Student Clearance

( ) Returned Textbooks ( you will be charged the actual price for any textbooks that are not returned or that are damaged)

( ) Returned All Other Materials

( ) Cleared Accounts Receivable (30 day policy)

( ) Provided Record Transfer Data

( ) Completed Daily Assignments

( ) Completed Quarterly Exams (if applicable)

FOR ADMINISTRATIVE REMARKS:

_________________________________________________________________________
                    _________________________________________________________________________
                    _________________________________________________________________________
                    _________________________________________________________________________

Approved by Director :

Signature : ___________________________________________

Date : ______________________