School District Online Learning Authorization

Student Information

Student Name:

Grade:

School Name:

Student ID (if applicable):

Parent/Guardian Information

Parent/Guardian Name:

Contact Phone:

Email Address:

Online Learning Authorization

Course(s) Authorized for Online Learning:

Reason for Online Learning:

Additional Notes:

Agreement

I authorize the above-named student to participate in the designated online learning program in accordance with district policies.

Parent/Guardian Signature:

Date:

School Administrator Signature:

Date: