Nonstandard Course Waiver Request Form

Nonstandard Course Waiver Request Form
Applicant Information
Corporation Name
Corporation Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name
School Number
Local Contact Person
Title
Phone Number

Area CodePhone Number
Email
example@example.com
Request Type

Intial RequestExtension of a Previous ApprovalAmendment to a Previous Approval
Waiver Type

Course ProposalLicensure ProposalCourse Proposal and Licensure
Waiver Length Requested

Authorization

Attach documentation (School Board minutes) of the governing body’s authorization to seek the requested Approval of State Board of Education Rules.
Documentation of the governing body's authorization to seek the requested approval of the State Board of Education. *

Browse Files

Cancelof
Superintendent's Name*

First NameLast Name
Signature*

Clear
Date*
Area CTE Director's Name (if applicable)

First NameLast Name
Signature

Clear
Date
If you are only requesting a licensure waiver, only the Licensure Waiver Information section needs to be completed. Questions can be directed to Adam McMickle: amcmickle@doe.in.gov.

Course Proposal Information (scroll to next page for licensure)

By submitting this application, you are requesting a waiver from 511 IAC 6.1-5-4.5
Title of Proposed Course(s)
Grade(s) to be served
Number of students participating
If High School Course, Give Number of Credits Offered:
If a single course, give length of course in semesters/trimesters with minutes of Instruction:
Describe the purpose of the proposed course and or curriculum program. Include how the proposed course or curriculum program will more effectively serve the needs of the students.
Describe the content of the proposed course. Attach any supporting materials, including course outlines. No more than 5 pages.
Are there any special contracts required to implement the proposal? If yes, please describe.
Describe the planning process. Include the extent of community, staff, and student involvement.
Describe how the effectiveness of the program will be evaluated. Especially the effects on learning outcomes. Evaluation of student progress, e.g., SAT, ISTEP+, iLearn, other norm referenced or criterion referenced scores, performance based assessment, informal type assessments, portfolios, etc.

Licensure Waiver Information (scroll to next page for licensure)

By submitting this application, you are requesting a waiver from 515 IAC 8-1
Teacher Name
License Number
Currently Content Areas on License
Requested Course Number
Requested Course Title
Describe education, work experience, and/or training that qualifies the teacher to teach outside the licensed area.
Describe efforts to find a properly licensed teacher. Why was the above teacher chosen?
If this is a renewal of a previously approved wavier, what efforts have been made to obtain appropriate licensure?
Should be Empty: