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Discontinuation of Coverage Form

Pre-tax Deduction Authorization Form

Last revised 9/15/2025

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Burbank USD

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Burbank Unified School District
1900 W. Olive Ave
Burbank
CA
91506
818-729-4400
Fax: 818-729-4483
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Nondiscrimination Statement: The Burbank Unified School District prohibits discrimination, intimidation, harassment (including sexual harassment) or bullying based on a person’s actual or perceived ancestry, color, disability, ethnicity, gender, gender expression, gender identity, immigration status, marital status, national origin, parental status, pregnancy status, race, sex, sexual orientation, or association with a person or group with one or more of these actual or perceived characteristics. For questions or complaints, contact Equity Compliance Officer: Peter Knapik, Ed.D., Assistant Superintendent of Educational Services, email; Title IX Coordinator: Peter Knapik, Ed.D., Assistant Superintendent of Educational Services, email; and Section 504 Coordinator: Narineh Barzegar, Director of Student Services, email. ADA Notification: If you use assistive technology and the format of any material on this web site interferes with your ability to access information, please contact Webmaster at (818) 729-4400. To enable us to respond in a manner most helpful to you, please indicate the nature of your accessibility problem, the preferred format in which to receive the material, the web address of the requested material, and your contact information.

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