Enter Your Contact Information
Select the option(s) below that pertain to you.
If you choose to withdraw your permission, the Georgia Office of Adult Education will not release your information for the purposes stated below. Your withdrawal will remain in effect unless you notify your Adult Education program otherwise. If you change your mind or have questions or concerns, please contact the staff at your Adult Education program or email firstname.lastname@example.org.
By typing my full name and today’s date, I attest to the following:
“I have read, understand, and agree to withdraw the above permission(s). I certify that the information submitted is true and accurate to the best of my knowledge, information, and belief, and is given freely and voluntarily by me without coercion, duress, threat, or promise of any kind.”
I understand that by typing my full name, I am electronically signing this form.