Supplemental Online Course Registration Form

ED-02400-06
Supplemental Online Course Registration Form
Definitions: A supplemental online course is an online course taken outside of the enrolling district in place of a course at the enrolling district. A K-12 public student may take up to 50% of their scheduled courses from an approved supplemental online course provider or more if the enrolling district and the online course provider agree. The enrolling district may reduce the number of courses they provide proportional to the supplemental online courses being taken. The grades, credits earned, and standards met are applied by the enrolling district to the student’s regular transcript. See Minn. Stat. 124D.094 [2023]. One form per student per term is required. This form may be transcribed and used electronically for course registrations by a supplemental online course provider. All fields must be included. Districts or charter schools offering online courses to their enrolled students are not required to collect this form from their own enrolled students.

Instructions: This form is to be completed by the student with their parent/guardian at the time of course registration. It must be turned in to the supplemental online course provider on or before the 15th school day after the enrolling district’s term has begun (unless there is an agreement to waive this deadline by the enrolling district and the online course provider

Section I: To be completed by the parent/guardian 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.

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

Information to be completed by the Student and Parent or Guardian
Student
Name (Last, First, M.I)
Date of Birth

MonthDayYear
Date
Current Grade Level
E-mail
example@example.com
Mobile phone
Alternate phone
Address

Address

Street Address Line 2

City, State ZIP codeState / Province

Postal / Zip Code
Parent 1/Guardian
Name (Last, First, M.I)
Mobile phone
Alternate phone
E-mail
example@example.com
Address (if different)

Address

Street Address Line 2

City, State ZIP codeState / Province

Postal / Zip Code
Contact preference

Phone CallTextEmail
Parent 2/Guardian 2
Name (Last, First, M.I)
Mobile phone
Alternate phone
E-mail
example@example.com
Address (if different)

Address

Street Address Line 2

City, State ZIP codeState / Province

Postal / Zip Code
Contact preference

Phone CallTextEmail
Online Course(s) Registration Request
Enrolling School
"home" school
Met with (name)
Counselor's name
Counselor Email
Date

MonthDayYear
Date
Term
Date submitted

MonthDayYear
Date
More than 50% of schedule?

YesNo

	Online course name	Replaces local course name
1.
2.
3.

I have discussed supplemental online course enrollment with my enrolling school representative indicated above. I have reviewed the online course(s) registration request and understand the expectations of enrolling in supplemental online courses.
Student Signature (required)

Clear
Date

MonthDayYear
Date
Parent/guardian Signature (required for students under 18 yrs old)

Clear
Print name and relationship
SECTION II

Supplemental Course Registration to be completed by the supplemental online course provider & enrolling provider.

(students/learning mentors, scroll to bottom and 'submit')
Program Name
Online Learning Program Coordinator
Phone Number
Fax Number
E-mail address
example@example.com
Online Learning Program Mailing Address
Enrolling School
The "home" school
District Number
ISD...
District Type
Site Number
Enrolling school 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 Number

Online Courses (courses may not exceed 50% of student's full schedule unless agreed to)

	Course	Start Date	*Meets graduation requirements
1.
2.
3.
4.
5.
6.

To be completed by the enrolling district:
Enter X for one of the following:

_X_ This coursework will substitute for other course work in the enrolling district and will be funded by the normal funding formula for online learning.

___ This coursework will substitute for other course work in the enrolling distric and will be funded by a contractual agreement with the enrolling district.

___ This coursework is being taken in addition to the regular district course work and the tuition will be paid by the student.

___ This is a private, non-resident or homeschool student and will pay tuition for which they will be billed.

___ This is an extended time course to support students who at risk for not grade progressing in the enrolling district and will be funded based on Minnesota Statutes, section 124D.68.

Enter X or check all that apply:

___ Enrolling district waives the 15 day deadline for enrollment.

___ Enrolling district waives 50% online learning credit limit.
Check if any applies

The student has an active IEP on file.The student is receiving ELL ServicesThe student qualifies as homeless/highly mobile.
Special Education Case Manager Name
E-mail address
example@example.com
Phone Number
I have shared the online learning course(s) syllabus with the enrolling district contact person.
OLL Provider & Title
Academic Excellence Online HS
Signature of AEO coordinator

Clear
Date

MonthDayYear
Date
I have reviewed the course syllabus and the course(s) checked meet the enrolling district’s graduation requirements.
Print name and title
Enrolling School counselor/contact
Signature

Clear
Date notification received

MonthDayYear
Date
Date signed and returned to OLL Provider

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

ED-02400-06

Supplemental Online Course Registration Form

Student

Parent 1/Guardian

Parent 2/Guardian 2

Online Course(s) Registration Request

To be completed by the enrolling district: