Parent Assurance Letter ENG

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Parent Assurance Letter ENG Powered By Docstoc
					                                            LOS ANGELES UNIFIED SCHOOL DISTRICT                                    Ramon C. Cortines
                                                                                                              Superintendent of Schools

                                                  Carlson Home/Hospital School                                            Janice Davis
                                                                                                            Administrator of Instruction
                                                       10952 Whipple Street                           Middle and High School Programs
                                                   North Hollywood, CA 91602
  Joe Salvemini                                     Telephone: (818) 509-8759                                           Jack Bagwell
  Principal                                                                                        Elementary Director, Local District 2
                                                    Facsimile: (818) 505-0246

                                                 PARENT ASSURANCE LETTER
                                                    (send upon discharge)

     Date: __________________________________                Carlson Teacher Name: ___________________________

     Student’s Name: ____________________________________________________________________________

     _______________________________________                 __________________________              __________________
                            Date of Birth                               Grade                                  Track

     I declare that I am the parent/guardian of _____________________________________ and I am withdrawing my
     son/daughter from this school due to the following reason (mark all that apply):
          (L2)  Enrolling in an LAUSD school—please indicate:
                    previous school /  different school ______________________________________________
                                                                                Name of new LAUSD school

          (L3)  Moving to another city in California. City name: __________________________________________
          (L4)  Enrolling in a private/non-public school. School name: _____________________________________
          (L5)  Moving to another state. Name of state: ________________________________________________
          (L5)  Moving to another country. Name of country: ____________________________________________
     I assure you that I will enroll my son/daughter in a school within a reasonable period of time.
     I declare under penalty of perjury under the laws of California that the above statements are true and correct.

     _____________________________________________ __________________________________________
               Parent/Guardian’s Name                                        Parent/Guardian’s Signature

               New Address

     _____________________________________________ __________________________________________
               New Phone Number                                                 Date

          (L1)  Student is expected to continue with Carlson. (PARENT SIGNATURE NOT REQUIRED!)

     ______________________________________________ __________________________________________
                     Carlson Teacher’s Name                                     Carlson Teacher’s Signature

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