2022-2023 Independent Study Referral

INDEPENDENT STUDY REFERRAL and CONTINUAL LEARNING PLAN

2022-2023 Duluth Area Learning Center
PARENTS/GUARDIANS: Please be sure to fill in Section 1 completely and sign before submitting. We cannot process enrollments without signatures.
Technology Village: 11 E Superior St, Suite 450, Duluth, MN 55802

Phone: (218) 336-8756 Fax: (218) 336-8770

This program is open to youth ages 16-20 who meet one or more of the state eligibility guidelines.

Independent Study is a digital curriculum with Teacher support

Classrooms will be open Monday-Thursday for full time Independent Study students 1:00 to 5:00 pm
Section 1

Student/Family Info
Name

First Name Middle Name Last Name
Student Date of Birth

MonthDay Year
Date
Gender

MaleFemale
GRADE
GRAD YEAR (GSY)
STUDENT PERSONAL EMAIL
example@example.com
STUDENT PHONE NUMBER
Include area code
Primary Address

Street Address

Street Address Line 2

City State

Zip Code
Parent/Guardian Name 1
Parent/Guardian Name 2
Parent/Guardian 1 Home/Cell Number
Parent/Guardian 2 Home/Cell Number
Parent/Guardian Email 1
example@example.com
Parent/Guardian Email 2
example@example.com
Note: if applicant is an out of district student please provide a "referring district" student data sheet with MARSS Number and complete this form for enrollment into the Duluth School District:

ISD709 Registration 22-23
Does student have a 504 plan?

YesNo
Does student receive Special Education Services (IEP)?

YesNo
If student has a 504/IEP plan, please submit a copy to ALC by any of the following options:
- Email
  - kathleen.wilson@isd709.org
  - valarie.wagenbach@isd709.org
- Fax
  - 218.336.8770
- Stop into ALC
  - Monday-Thursday
  - 8:00am-5:00pm
Current Services

Student qualifies for Families in Transition
Please check all that apply

Performs substantially below the performance level for pupils of the same age in locally determined achievement testHas experienced mental health problemsHas experienced homelessness sometime within six months before requesting a transfer to an eligible programSpeaks English as a second language or has limited English proficiency (LEP)Has been excluded or expelled according to sections 121A.40 to 121A.56Has been referred by a school district for enrollment in an eligible program or program pursuant to section 124D.69Is a victim of physical or sexual abuseIs at least one year behind in satisfactorily completing coursework or obtaining credits for graduationIs pregnant or is a parentHas been assessed as chemically dependentHas withdrawn from school or has been chronically truant
SIGNATURES
I (student) understand the ALC program requirements. I will work cooperatively with my counselor to develop a Continual Learning Plan (CLP) and promise to put forth full effort to achieve my stated goals.
Student Signature/Agreement

Clear
Date

MonthDay Year
Date
I (parent/guardian) understand the ALC program requirements. I support the decision of my son/daughter to enroll in the program and expect him/her to work cooperatively with his/her counselor to develop a Continual Learning Plan (CLP) and to put forth full effort to achieve the stated goals.
Parent or Guardian/Agreement

Clear
Date

MonthDay Year
Date
Section 2

STAFF ONLY
Please select Class(es), Semester (A or B) and Credit amount (0.5 or 1.0)
English 9AB0.51.0
English 10AB0.51.0
English 11 (includes Am.Lit)AB0.51.0
Values in Literature0.5
Grammar & Composition0.5
Civics in Global Society0.5
United States HistoryAB0.51.0
World HistoryAB0.51.0
Economics0.5
American Government0.5
Intermediate Algebra IAB0.51.0
Algebra IIAB0.51.0
GeometryAB0.51.0
Probabilities and StatsAB0.5
Physical ScienceAB0.51.0
BiologyAB0.51.0
PhysicsAB0.51.0
ChemistryAB0.51.0
Work Experience Seminar0.5
Work Experience Internship (Seminar Prerequisite)0.51.0
Health0.5
Physical Education0.5
Music0.5
Art0.5
Spanish IAB0.51.0
School
Educational Goals for the current school year
Courses student is enrolling in
Counselor/Admin. Signature

Clear
Date

MonthDay Year
Date
Counselor/Admin. Signature is necessary for any student who has attended ISD709 classes within the past 12 months
Should be Empty:

INDEPENDENT STUDY REFERRAL and CONTINUAL LEARNING PLAN

Section 1

SIGNATURES

Section 2