Request for Extended Vacation

A scholar on an extended vacation lasting more than 10 consecutive school days, but no more than four months (cumulatively or consecutively) in one school year will not be deemed to have lost California residency but must submit this form 10 days prior to departure.
Who is preparing/ submitting this form?*

Learning coach (not parent/guardian of scholar)Parent/Guardian who is the learning coachSupervising teacher
Learning Coach Name*

First NameLast Name
Learning Coach E-mail*
example@example.com
Learning Coach Phone Number*
Learning Coach/ Family Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many scholars are enrolled with Compass?*

1234567+
Scholar #1 Name*

First NameLast Name
Which program is Scholar #1 enrolled in?*
Scholar #2 Name

First NameLast Name
Which program is Scholar #2 enrolled in?*
Scholar #3 Name

First NameLast Name
Which program is Scholar #3 enrolled in?*
Scholar #4 Name

First NameLast Name
Which program is Scholar #4 enrolled in?*
Scholar #5 Name

First NameLast Name
Which program is Scholar #5 enrolled in?*
Scholar #6 Name

First NameLast Name
Which program is Scholar #6 enrolled in?*
Scholar #7 Name

First NameLast Name
Which program is Scholar #7 enrolled in?*
Who is/ are your assigned Supervising Teacher? *
(You can select multiple if applicable by holding down CTRL and clicking on multiple teacher names)
Please enter your supervising teacher's email. A copy of this form will be sent to them for their information as well. *
example@example.com
Please enter 2nd supervising teacher's email if applicable. Some families have different supervising teachers for each scholar depending on grade level or program.
example@example.com
Travel Information
Departure Date*

MonthDayYear
Date
Return Date*

MonthDayYear
Date
Please read the following statements and check all to in order to proceed:*
Please read the following statements and check all to in order to proceed:*
E-Signature*

Clear
Should be Empty:

A scholar on an extended vacation lasting more than 10 consecutive school days, but no more than four months (cumulatively or consecutively) in one school year will not be deemed to have lost California residency but must submit this form 10 days prior to departure.

Travel Information