Online Learning Supplemental Notice of Student Registration

Online Learning Supplemental Notice of Student Registration
INSTRUCTIONS: The online learning supplemental notice of student registration is used to register for a supplemental online learning course from an approved public school online learning provider. Supplemental online learning means an online course taken in place of a course period during the regular school day at a local district.

One form per student, per term is required. If you would like to print a form and complete by hand, please email valarie.wagenbach@isd709.org

Section I: To be completed by the parents and student after they have had initial meetings with the enrolling district and online learning provider. Please sign only after you have reviewed the online course and program and understand the expectations of enrolling in online learning.

Please make sure to either choose a counselor/dean of students or provide the email for a school contact.

Section II: To be completed by the online learning provider and enrolling district online contact person. Each school should keep a copy of this form when all signatures have been secured. The enrolling district has 15 days to review the attached course syllabus and sign and submit the form to the online learning provider.
SECTION I: IDENTIFICATION INFORMATION TO BE COMPLETED BY THE STUDENT AND PARENT/GUARDIAN
Student Name (Last, First, M.I.)
Date of Birth

MonthDayYear
Date
Gender
Student’s e-mail
example@example.com
Student’s home phone
Student’s cell phone
Address

Address

Street Address Line 2

City, State Zip codeState / Province

Postal / Zip Code
Current Grade Level
Enrolling School
Student MARSS Number
Last Grade Completed
Parent 1/Guardian Name (Last, First, M.I.)
Home Phone
Parent 1 work phone
Address

Parent 1/Guardian Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Parent 1/Guardian's E-mail (if different from student)
example@example.com
Parent 1 cell phone
Parent 2/Guardian Name Last, First, M.I
Home Phone
Parent 2 work phone
Parent 2/Guardian Address

Address

City, State, Zip Code

CityState / Province

Postal / Zip Code
Parent 2/Guardian's Email (if different from student)
example@example.com
Parent 2 cell phone
Student reason for enrolling in online learning. Check one of the following:

Course not offered at schoolSchedule ConflictEnrichment/Advanced learning opportunityCredit recoveryIf Credit Recovery, course(s) being taken in addition to a full-time scheduleOther
Type(s) of internet connection you will be using to access your course. Check one of the following:

Dial-up ModemCable/DSLHigh Speed Home ConnectionHigh Speed School ConnectionNo Internet access - I plan to participate in this course at (write answer in 'other')Other
Choose counselor/dean of students
If counselor/dean of students is not listed please provide email
example@example.com
I have discussed enrollment in online learning with my enrolling school representative and the online learning program representative.

I have reviewed the online course(s)and program listed on page 2 and understand the expectations of enrolling in online learning
Student Signature (required):*

Clear
Date

MonthDayYear
Date
Parent’s signature required for students under 18 years old.
Parent Signature*

Clear
Print name and relationship
SECTION II: OLL PROGRAM PLAN

TO BE COMPLETED BY OLL PROGRAM PROVIDER AND ENROLLING SCHOOL CONTACT PERSON Online Learning (OLL)
Program
Telephone
FAX
Online Learning Program Coordinator
E-mail address
Online Learning Program Mailing Address
Enrolling School
District Number
District Type
School Number
Telephone
Fax
Please enter a valid phone number.
Enrolling School Contact Person or Counselor
E-mail address
example@example.com
Enrolling School Mailing Address

Enrolling School Mailing Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
OLL proposed plan for
Student name
Student MARSS
Please type in all OLL Courses the student would like to participate in.

(courses may not exceed 60% of student's full schedule)
OLL Course
OLL Course
OLL Course
OLL Course
OLL Course
OLL Course
The enrolling district (home school) agrees:

- This coursework will substitute for other course work in the enrolling district (home school) and will be funded by the normal funding formula for online learning.

- Accepts credits based on MN Statue 124D.095

- The student has notified the enrolling district before the midpoint of the current term.
This Student is receiving ELL Services

Yes
The student has an Active IEP on File

Yes
If student has an active IEP please provide the following information:
Special Education Case Manager Name
Email
example@example.com
Phone
I have reviewed the course syllabus and the course(s) checked meet the enrolling district's graduation requirements. Signature of enrolling district online learning contact person

Clear
Date notification received

MonthDayYear
Date
Date signed and returned to OLL Provider

MonthDayYear
Date
Print name and title
I have shared the online learning course(s) syllabus with the enrolling district contact person. Signature of OLL provider contact person (Chris Vold):

Clear
Print name and title
Date

MonthDayYear
Date
Schedule changes may not be made after the midpoint of enrolling district’s term unless waived by both schools. ATTN: Upon completion submit this form to the online learning provider in section II.
Should be Empty: