2024-2025 Seat-Based COMBINED

SEAT-BASED REFERRAL and CONTINUAL LEARNING PLAN

2024-2025 Duluth Area Learning Center
STOP! Submitting this form will END enrollment at your student's current school. If your intention is to completely transfer to ALC online, please continue and fill out this form.

If you are looking for CREDIT RECOVERY (making up credit for failed or missing requirements), please contact your home school's counselor to begin that enrollment process.

PARENTS/GUARDIANS: Please be sure to fill in Section 1 completely and sign before submitting. We cannot process enrollments without signatures.
Technology Village: 11 E Superior St, Suite 450, Duluth, MN 55802

Phone: (218) 336-8756 Fax: (218) 336-8770

This program is open to youth ages 16-20 who meet one or more of the state eligibility guidelines.

Independent Study is a digital curriculum with Teacher support

Classrooms will be open Monday-Thursday for full time Independent Study students 8:00am to 5:00 pm or by appointment with teacher.
Section 1

Student/Family Info
Name

First NameMiddle NameLast Name
Student Date of Birth

MonthDayYear
Date
Gender

MaleFemale
GRADE
GRAD YEAR (GSY)
STUDENT PERSONAL EMAIL
NOT isd709 or parent email, please
STUDENT PHONE NUMBER
Include area code
Previous School Enrollment?
Where should we request records from?
Primary Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Name 1
Parent/Guardian Name 2
Parent/Guardian 1 Home/Cell Number
Parent/Guardian 2 Home/Cell Number
Parent/Guardian Email 1
example@example.com
Parent/Guardian Email 2
example@example.com
Note: if applicant is an out of district student please provide a "referring district" student data sheet with MARSS Number and complete this form for enrollment into the Duluth School District:

Duluth Public Schools Registration Form 24-25
Current Services

Student qualifies for Families in Transition
Does student have a 504 plan?

YesNo
Does student receive Special Education Services (IEP)?

YesNo
If student has a 504/IEP plan, please submit a copy to ALC by any of the following options:
- Email
  - kathleen.wilson@isd709.org
  - valarie.wagenbach@isd709.org
- Fax
  - 218.336.8770
- Stop into ALC
  - Monday-Thursday
  - 8:00am-5:00pm
If student has IEP, Case Manager's name:
Case Manager's email:
** REQUIRED ** ALC students must meet MN state requirements for enrollment. Please check all that apply*

Performs substantially below the performance level for pupils of the same age in locally determined achievement testHas experienced mental health problemsHas experienced homelessness sometime within six months before requesting a transfer to an eligible programSpeaks English as a second language or has limited English proficiency (LEP)Has been excluded or expelled according to sections 121A.40 to 121A.56Has been referred by a school district for enrollment in an eligible program or program pursuant to section 124D.69Is a victim of physical or sexual abuseIs at least one year behind in satisfactorily completing coursework or obtaining credits for graduationIs pregnant or is a parentHas been assessed as chemically dependentHas withdrawn from school or has been chronically truant
** REQUIRED ** Educational Goals for the current school year*
Annual Health History/Immunizations/OTC Self Medication
*** Note for Parent/Guardians ***

Prior to the beginning of each school year, emergency care plans and medication authorizations should be turned in to your child's school health office and reviewed with the Licensed School Nurse.

All students must comply with Minnesota state statute 121A.15 with regards to immunizations. Exclusion from school will occur if immunizations, medical exemption or objection requirements are not met.

For your convenience, we have combined forms into one to eliminate the need for you to enter duplicate information multiple times. Please make sure you read through everything so you know what you are signing, parts of these forms may be subject to review by the State of Minnesota.

Forms and exemptions must be completed by September 18, 2024.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.
Dentist's Name
Dentist's Phone Number
Please enter a valid phone number.
Hospital Preference
(Essentia or St. Luke's)
School attended last year:
Is student covered by health insurance?

YesNo
If yes, is it:

Medical AssistanceMinnesota CarePrivate/Employer provided
In case of emergency / illness at school and parents can not be reached, call:
Name (person to call first)
Cell phone
Please enter a valid phone number.
Work phone
Please enter a valid phone number.
Home phone
Please enter a valid phone number.
Name (person to call second)
Cell phone
Please enter a valid phone number.
Work phone
Please enter a valid phone number.
Home phone
Please enter a valid phone number.
Student Allergies?
Current Health Diagnosis/Conditions (physical &/or mental health): (example: Asthma, Diabetes, ADHD)
Serious illness, operation, hospitalization or accidents within the last 12 months
Medications (at home &/or at school) - provide drug name, dosage & times taken
Date of last eye exam:
By Dr ?:
Glasses?

YesNo
Contacts?

YesNo
Reason for glasses?

NearsightedFarsightedOther
Date of last physical exam:
By Dr ?:
Date of last dental exam:
By Dr ?:
When prescription medication is to be taken in school: Contact the School Health Office.

Policy requires that a pharmacy labeled container of the medication be provided, along with written parent/guardian & prescriber permission. Medication forms are available from the school health office. The school is able to fax the provider for permission once parent/guardian signature has been obtained.
Parent & student agree to:

Student is knowledgeable about the medication and how to administer it.
Student has the skills to safely possess and use the medication.
Student may self-administer the medication.
Student will follow parent/guardian instruction and NOT allow anyone else to use the medication.
Student will use correct medication administration technique & proper dosing.
Contact the nurse if student suspects that he/she may be experiencing side effects from medication.
Medication must be provided by the parent/guardian and must be in a properly labeled container and have manufacturers' recommendations clearly available.

I understand that permission for self-administration of medication may be suspended if I am unable to follow the procedure outlined.
SELF-ADMINISTRATION OF NON-PRESCRIPTION PAIN MEDICATION AUTHORIZATION

A secondary student (grades 7-12) may possess and use nonprescription pain relief in a manner consistent with the labeling, when the school has received a written authorization from the student's parent or guardian permitting the student to self-administer the medication. The school may revoke a student's privilege to possess and use non-prescription pain relievers if the school determines that the student is abusing the privilege. Students may not possess or use any drug or product containing ephedrine or pseudoephedrine.

This form must be completed by the parent/guardian/student and returned to the school health office ANNUALLY:
I believe that this student is capable of self-administering the following medication: .
, by mouth, per package instructions. I request self-administration of this medication for the treatment of Type a label.
Immunization Information

Use this chart as a guide to determine which vaccines are required to enroll in child care, early childhood programs, and school (public or private.)

Find the child's age/grade level and look to see if your child had the number of shots shown by the checkmarks under each vaccine. Children birth to age 2 may not have received all doses.
PLEASE ATTACH A COPY OF YOUR STUDENT'S CURRENT IMMUNIZATION RECORD:

Cancelof
IMPORTANT IMMUNIZATION INFORMATION & EXEMPTIONS:

You are required to attach a copy of your student's immunization records above.

If your student has a medical exemption for any of the above vaccines, please call ALC (218-336-8756) for a paper copy of the form your health care practitioner must sign.

If your student has a non-medical exemption for any of the above vaccines, please call ALC (218-336-8756) for a paper copy of the form you must sign in the presense of a MN State Notary.

If your student has had chickenpox (varicella) before 9/1/2010 OR has been previously diagnosed with it, they are medically exempt from the chickenpox vaccine, please call ALC (218-336-8756) for a paper copy of the form you or your health care practitioner must sign.

DISCLOSURE OF PROTECTED HEALTH INFORMATION

I may refuse to sign this annual health history and it will not affect my child's ability to receive educational services.

Please contact ALC at 218-336-8756 if you cannot sign for all of the above and we will provide a paper copy so you can sign only the portions you agree with.

The laws that protect the information identified on the Annual Health History in some situations may allow or require this entity to disclose this information, but only as permitted by law Health Insurance Portability and Accountability Act (HIPAA) Family Educational Rights and Privacy Act (FERPA), Minnesota Government Data Practices Act (MGDPA) or Chapter 13.

HS-6a (Rev. 4/16) Item #35-15-000105
SIGNATURES
*** IMPORTANT *** Read before you submit.

** Parent/Guardian signature here indicates the above information is true in regards to health history, self-administration of non-prescription pain meds, and immunization records, as well as allowing my child’s school to share my child’s immunization documentation with Minnesota’s immunization information system.

Consent to share immunization information: This school is asking for permission
to share your child’s immunization record with Minnesota’s immunization informationsystem. Giving your permission will:
• Provide easier access for you and your school to check immunization records, such as at school entry each year.
• Support your school in helping to protect students by knowing who may be
vulnerable to disease based on their immunization record. This can be important
during a disease outbreak.

Under Minnesota law, all the information you provide is private and can only be released to those authorized to receive it. Signing this section of the form is optional. If you choose not to sign, it will not affect the health or educational services your child receives.

Please contact ALC at 218-336-8756 if you cannot sign for all of the above and we will provide a paper copy so you can sign only the portions you agree with.

Please visit ISD709 Health Services for more information (LEFT CLICK to open in a new page so you don't lose your work above!).

HS-49e (Rev. 4/16) Item #35-15-000885

I (student) understand the ALC program requirements. I will work cooperatively with my counselor to develop a Continual Learning Plan (CLP) and promise to put forth full effort to achieve my stated goals.
Student Signature/Agreement

Clear
Date

MonthDayYear
Date
I (parent/guardian) understand the ALC program requirements. I support the decision of my son/daughter to enroll in the program and expect him/her to work cooperatively with his/her counselor to develop a Continual Learning Plan (CLP) and to put forth full effort to achieve the stated goals. * Signature also includes permission for educational, school sponsored field trips.
Parent or Guardian/Agreement

Clear
Date

MonthDayYear
Date
Courses student is enrolling in
Counselor/Admin. Signature

Clear
Date

MonthDayYear
Date
Counselor/Admin. Signature is necessary for any student who has attended ISD709 classes within the past 12 months
Should be Empty:

SEAT-BASED REFERRAL and CONTINUAL LEARNING PLAN

Section 1

Annual Health History/Immunizations/OTC Self Medication

SIGNATURES