Series 640.2.2P - Application for Shared-Time Enrollment of Home School Students in Middle School or High School Curriculum Courses

Complete page 1 of this application and return it by June 1 to:  Director of Community Education, 15180 Canada Avenue, Rosemount, MN  55068.

GENERAL INFORMATION – print

 

                                                                                                                            

student name                                                        date of birth

                                                                                                                            

parent/guardian name(s)

                                                                                                                            

address                                                                                     city/zip

                                                                                                                            

home phone                    cell phone                       work phone                    email address

District 196 school attendance area                                                                        

I have read Administrative Regulation 640.2.2AR, Home School Shared Time Students in Middle School and High School Curricular Courses:  □ Yes            □ No

X                                                                                                                         

          signature of parent or guardian (or student if 18 years of age or older)                             date

DISTRICT 196 COURSE(S) REQUESTED

 

School Year:  20     -                  Grade          

Course                                                                                                                  

           For:   □ 1  □ 2  □ 3  Trimester              OR               □ 1  □ 2  □ 3  □ 4  Quarter

Course                                                                                                                  

           For:   □ 1  □ 2  □ 3  Trimester              OR               □ 1  □ 2  □ 3  □ 4  Quarter

At middle school checked below:

□ Black Hawk

□ Dakota Hills

□ Falcon Ridge

□ Rosemount

□ Scott Highlands

□ Valley Middle School of STEM 

At high school checked below:

□ Apple Valley

□ Eagan

□ Eastview

□ Rosemount

FOR DISTRICT USE ONLY

VERIFICATION

According to our records, the student listed on page 1 is a home school student in compliance with the Minnesota Compulsory Instruction Law and resides in District 196.

X                                                                                                                        

signature of Director of Community Education                   date

PRINCIPAL’S RECOMMENDATION

□ Accept this application                               □ Do not accept this application

Conditions for acceptance (if any):                                                                           

                                                                                                                            

                                                                                                                            

Reasons for rejecting application:                                                                               

                                                                                                                            

                                                                                                                          

X                                                                                                                        

signature of Principal                                                                 date

DIRECTOR OF SECONDARY EDUCATION

□ Preliminary approval of principal’s recommendation

□ Preliminary disapproval of principal’s recommendation

□ Space available – student permitted to enroll in the following high school

Course(s) (specify):                                                                              

at                                                                 Middle School/High School

X                                                                           

signature of Director of Secondary Education      date

c:       Home School

          Middle School or High School Principal

          Director of Community Education

          Student Information Supervisor (if application is approved)

Procedure/640.2.2P/12-12-16