Form Ed 02400 04 – Fill Out and Use This PDF

GENERAL INSTRUCTIONS: The online learning supplemental notice of student registration is used to register for a supplemental online learning course from a certified 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

SUBMIT the completed form to the online learning provider listed in section II. One form per student per term is required.

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.

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 OR GUARDIAN

	Student Name (Last, First, M.I.):			Date of Birth:	Gender:
	Student’s e-mail:	Student’s home phone:		Student’s cell phone:
	Address:	City, State Zip code:		Current Grade Level:
	Enrolling School:	Student MARSS Number:		Last Grade Completed:
	Mother/Guardian Name (Last, First, M.I.):			Home phone:
				Mother’s work phone:
	Mother/Guardian Address:		City, State, Zip Code:

No internet access – I plan to participate in this course at:

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:	Date:
(required)
Parent Signature:	Print name and relationship:
(required for students under 18 years old)

Online Learning (OLL) Program:			Telephone:
			Fax:
Online Learning Program Coordinator:			E-mail address:
Online Learning Program Mailing Address:			City, State, Zip Code:
Enrolling School:		District Number:	Telephone:
			Fax:
Enrolling School Contact Person or Counselor:			E-mail address:
Enrolling School Mailing Address:			City, State, Zip Code:
OLL proposed plan for __	_________________________________________________Student MARSS #___			__________

(student name)

To be completed by the enrolling district:

Check one of the following:

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 district 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. I am a private or homeschool student and will pay tuition for which I will be billed

Check one of the following:

Accepts credits based on MN Statue 124D.095

Enrolling district waives 50% online learning credit limit

A separate agreement has been made for exceeding 50% registration limit between the OLL provider and the enrolling district.

Check one of the following:
The student has notified the enrolling district before the midpoint of the current term.	Midpoint Date:
The student has NOT notified the enrolling district before the midpoint of the current term, but we have elected to waive this requirement.
The student has NOT notified our district before the midpoint of the current term, and the student is responsible for the paying of tuition
Check if it applies:
The student has an active IEP on file If checked please provide the following information:
Special Education Case Manager Name:	E-mail address:	Phone
The student is receiving ELL services

I have shared the online learning course(s) syllabus with the enrolling district contact person.

Signature of OLL provider contact person

Print name and title

Date (please submit to enrolling district contact person)

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

Print name and titleDate notification receivedDate signed and returned to OLL Provider

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.