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