PARENT SELECTION OF REMOTE LEARNING          NEW Remote Requests ONLY    
Please complete this form IF you have NOT completed the first form for remote learning . If you have already been approved for remote learning  DO NOT complete this form.

Please complete 1 form for each child for whom you are making a request.

Please answer the following questions regarding your request for remote instruction for your child.
Should you have any questions regarding the remote learning option, please contact your child’s building principal.

The school district may require a period of at least thirty calendar (30) days to process your request as it may necessitate a change in instructional staff and instructional support staff, educational technology and student schedule.

Please be sure to provide your contact information below in the event that the school principal requires additional information and so that he/she can keep you informed on the status of your child’s transition to remote learning.

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Student LAST Name *
Student FIRST Name *
School *
Grade *
Parent/Guardian’s LAST Name *
Parent/Guardian’s FIRST Name *
Address *
Telephone Number: *
Email *
Preferred contact method: *
Required
Does your child have an Individualized Education Program (“IEP”) or 504 Plan?                                        *Please know that a student’s return from or placement on full-time remote instruction will require an amendment to the IEP or 504 Plan.   *
Required
Did your child qualify for student transportation services for the 2020-2021 School year?                                           *Requests for full-time remote instruction will result in the termination of your child’s school transportation services. *
Required
Please select the services for which you are requesting to be provided entirely remotely (select all that apply):                  *For those services that you have not selected, they will be provided in-school and in accordance with your child’s current schedule.  You will be responsible for transporting your child to and from school for these services, at the designated times and days.  Parents/guardians are reminded that they are to adhere to the Board’s Visitor Policy No. 9150, and the Board’s Policy concerning the Restart and Reopening of Schools due to COVID-19, No. 8210 and 8220. *
Required
If you selected RELATED SERVICES for the above question, which are you requesting to be provided entirely remotely? (See Above.  List all that apply):
If you selected OTHER for the above question, which are you requesting to be provided entirely remotely? (Please write a short description):
Digital Signature *
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