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Code No.  501.9E1


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)

Approved 7-20-2020   Reviewed 10-16-2023