North Pemiscot R-1 Virtual Learning Application
2020-2021
Name of Student *
Grade of Student *
Birthdate: *
MM
/
DD
/
YYYY
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. *
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