Norwalk-La Mirada Unified School District
Student and Family Services Department
12820 Pioneer Blvd. Norwalk, CA 90650
AB 104 – Retention Consultation Request
(This request must be received by the Student Services Department by August 6, 2021)
For the 2021-22 academic year, AB 104 bill requires an LEA to offer the parent/guardian a consultation
upon receiving a written request to retain an eligible pupil. “Eligible Pupil” is defined as a pupil who
has received “deficient grades for at least one-half of the pupil’s coursework in the 2020-21academic
year.”
Parent/Guardian: Phone Number:
Student Name: Student Number:
Grade (20-21 school year): School: Teacher:
Subject: Request for Retention Consultation
In the area below, note anything else you would like considered during the retention consultation
meeting:
We, the parents/guardians of the above named student, request a retention consultation as our student
is an eligible pupil.
Parent/Guardian Signature Date:
click to sign
signature
click to edit
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