Date: ________________
Student Name: ____________________________ Attendance Center: ______________________
Parent/Guardian: ___________________________
I, _________________________ (Parent/Guardian) am requesting accommodation for my child,__________________________(Student Name) to participate in remote learning opportunities for the duration of the declared public emergency, or until I have determined my child can safely return to traditional in-person learning at his/her designated attendance center, whichever occurs first.
I have attached to this form documentation from an Iowa Board of Medicine-licensed medical professional confirming that remote learning is medically necessary due to the vulnerable health condition of my child or of a family member residing within the same home as my child.
I understand that the district will do their utmost to accommodate my child’s learning needs, but that some learning opportunities may need to be modified in a remote environment. The provision of special education and accommodations for students who have individualized education programs (IEPs) or Section 504 plans will be determined by each respective IEP or Section 504 team.
I understand that in order for my child to continue to participate in mandatory learning, his/her remote attendance will be taken, assessments administered, and grades will be counted toward my child’s cumulative grade average. I understand that any devices, technology, or materials given to my child to facilitate remote learning are the property of the district and must be returned at the end of the remote learning period.
I am requesting that remote learning opportunities begin on ______________ (date) and continue until
[_____________(date) or the declared public emergency is dismissed].
(Parent/Guardian) ____________________________________
(Date) ________________
Request approved by: __________________________________ (School official) _____________________
(Date) ________________
Note: This form is to be utilized by parents/guardians of a student who, during the course of a declared public emergency, believe that further attendance by the student at traditional in person school would be detrimental to the health or safety of the student or the student’s family member residing with the student. This form is not necessary when the school building is closed to traditional in person learning and remote learning opportunities are already available to students. It is only to be utilized during a public emergency declared by state or local officials when traditional in person learning continues to be held.
