PVMS Change of Status Form
LRSD students will be required to remain in their selected learning environment until the end of the quarter (9 weeks). Parents/ guardians will be able to request a change between virtual and in-person learning. All efforts will be made to provide a smooth transition; however, depending on the grade level and content area, the teacher of record may or may not remain the same. In extenuating circumstances, parents will be allowed to change their student’s learning environment at any time.

The following criteria will be considered if a student requests a change in instructional methods (in-person or virtual) for an extenuating circumstance:

1. The student tests positive for COVID-19;

2. The student has a family member or someone in the home who tests positive for COVID-19;

3. The student has been in close contact with someone who has tested positive for COVID-19;

4. Students with certain underlying medical conditions who are considered at risk for severe illness from COVID-19 as defined by the CDC and/or

5. Parent/ guardian provides written documentation that the child can no longer be supervised in the home due to parent/ guardian work/ employment status.

The parent or guardian should submit the request for change of learning environment in writing to the child’s principal; the request should include the reason for the requested change. The change request form will be reviewed by the principal or designee to determine the feasibility of the requested change. The parent/ guardian will be notified of next steps. The child will continue to participate in the original mode of delivery until the request has been finalized and the parent notified. The timeline may be altered in extenuating circumstances.
Student Name *
Student ID *
Grade Level *
Current Learning Environment *
Switching to (learning environment)
Clear selection
Parent/Guardian Name *
Parent Email Address *
Parent Telephone Number *
Never submit passwords through Google Forms.
This form was created inside of Little Rock School District. Report Abuse