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Request for 100% Virtual Learning: 2020-2021
Please complete one form per student.
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* Indicates required question
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Student's Street Address
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Your answer
City/State/Zip
*
Your answer
Student's ID Number
*
Your answer
School Student Attends
*
Choose
Tappahannock Elementary School
Essex Intermediate School
Essex High School
Student's Grade Level for 2020-2021
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PreK
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Parent/Guardian Name
*
Your answer
Parent/Guardian Address
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Your answer
Parent/Guardian Phone Number
*
Your answer
Parent/Guardian Email Address
*
Your answer
Please give your reason(s) for requesting 100% virtual learning. (Please select all that apply.)
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Medical condition resulting in greater risk for COVID-19
Fear/anxiety related to COVID-19
Disagreement with restrictions and safety precautions being implemented within schools as a result of COVID-19 (face coverings, social distancing, three-week rotation schedule)
General preference for at-home/virtual learning
Other:
Required
Please describe the student's internet access. (Please select all that apply.)
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Consistent, high-speed internet is available and will be used by the student for virtual learning.
Dependable high-speed internet is a concern and is not consistently available in our home.
My child has a reliable device to use for virtual learning.
Other:
Required
Please initial here to acknowledge your request for 100% Virtual Learning.
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Your answer
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