2024-2025 WITHDRAWAL FORM

2024-2025 WITHDRAWAL FORM
PALMETTO SCHOLARS' ACADEMY

7499 Dorchester Road. North Charleston, SC 29418 Phone: 843-300-4118 Fax: 843-300-4123 Principal: Dr. Kimberly Zerbst
Student *
Withdrawal Information*
Reason for Withdrawal from PSA*
Student Home Address*
Parent/Guardian 1 Information
Parent/Guardian 2 Information
Returned Book(s)
The student has returned their PSA Chromebook to Mrs. Miller.

YesOther
Legal Parent/Guardian Acknowledgement*
I am officially withdrawing this student from Palmetto Scholars Academy (PSA) for the above reason. I understand that if the student has not returned all books/items that belong to PSA the student's records may not be forwarded to their next school.

Please electronically sign this form below indicating all information on this form is true/correct and this agreement to withdrawal the student from PSA is binding.

*The electronic signature is in accordance with the Esign Act and has the same legal status as a handwritten signature. All parties agree that this agreement may be electronically signed and the electronic signature appearing on this agreement is for the purpose of validity, enforceability, and admissibility.
Parent Electronic Signature**

Clear
Today's Date*

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Date
Correspondence Email
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PALMETTO SCHOLARS' ACADEMY