Name of Student *

Grade of Student *

Birthdate: *

Address *

Parent/Guardian E-mail Address

Contact Phone Number *

Does the student have an I.E.P.? *

Does the student have a 504 Plan? *

Reason for requesting the North Pemiscot R-1 Virtual Learning Program *

We have read the North Pemiscot Re-entry plan and understand and agree to follow all requirements and expectations set forth to successfully complete the Virtual Learning Program. *