North Pemiscot R-1 Virtual Learning Application
2020-2021
* Required
Name of Student
*
Your answer
Grade of Student
*
Your answer
Birthdate:
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MM
/
DD
/
YYYY
Address
*
Your answer
Parent/Guardian E-mail Address
Your answer
Contact Phone Number
*
Your answer
Does the student have an I.E.P.?
*
Yes
No
Does the student have a 504 Plan?
*
Yes
No
Reason for requesting the North Pemiscot R-1 Virtual Learning Program
*
Your answer
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.
*
Yes
No
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