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Short Term Independent Study Agreement Form (Mitchell K-6)

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Master Agreement for the Atwater Elementary School District 2022-2023
Short Term Independent Study Request / Solicitud de Estudio Independiente de Corto Plazo

Student Full Name:*

Nombre Completo del Estudiante:

Answer required for "Student Full Name:"

Student Lunch ID #:

# del Estudiante:

Answer required for "Student Lunch ID #:"

Student Grade Level:*

Grado:

Answer required for "Student Grade Level:"

Teacher:*

Maestro(a):

Answer required for "Teacher:"

Duration of contract:
Duración del contrato:

Start Date:*

Fecha de Entrada:

Answer required for "Start Date:"

End Date:*

Fecha de Salida:

Answer required for "End Date:"

Phone Number:*

Teléfono:

Number Required

Reason for requesting Independent Study:*

Razón para la solicitud de estudio independiente:

Answer required for "Reason for requesting Independent Study:"

☛ I acknowledge reviewing, understanding, and being bound by the Atwater Elementary School District terms of Agreement and hereby agree to all the provisions set forth. ❐ Terms of Agreement
Reconozco haber revisado, comprendido y obligado(a) por los términos del Acuerdo del Distrito Escolar Primario de Atwater y acepto todas las disposiciones establecidas. ❐ Términos del acuerdo

☛ I attest all of the information entered is accurate.
Testifico que toda la información ingresada es precisa.

☛ By typing my name below, I understand and agree that this form of electronic signature has the same legal force and affect as a manual signature.
Al escribir mi nombre, entiendo y acepto que esta forma de firma electrónica tiene la misma fuerza legal y efecto que una firma manual.

☛ Parent/Guardian/Caregiver Name:*

Firma del Padre/Tutor:

Answer required for "☛ Parent/Guardian/Caregiver Name:"

Today's Date:*

Fecha:

Answer required for "Today's Date:"

Confirmation Email

Answer required for "Confirmation Email"