Supplemental Online Course Registration Form

MSAD Online Academy Course Registration Form

(This form was adapted by MSAD from the MN Department of Education's Supplemental Online Course Registration Form that can be found here.)

Is online right for me? For more information read here.
Definitions: A supplemental online course is an online course taken outside of the enrolling district in place of a course at the enrolling district. A K-12 public student may take up to 50% of their scheduled courses from an approved supplemental online course provider or more if the enrolling district and the online course provider agree. The enrolling district may reduce the number of courses they provide proportional to the supplemental online courses being taken. The grades, credits earned, and standards met are applied by the enrolling district to the student's regular transcript. See Minn. Stat. 124D.094 [2023]. One form per student per term is required. This form may be transcribed and used electronically for course registrations by a supplemental online course provider. All fields must be included. Districts or charter schools offering online courses to their enrolled students are not required to collect this form from their own enrolled students.

Instructions: This form is to be completed by the student with their parent/guardian at the time of course registration. It must be turned in to the supplemental online course provider on or before the 15th school day after the enrolling district's term has begun (unless there is an agreement to waive this deadline by the enrolling district and the online course provider).

Section I: To be completed by the parent/guardian and student after they have had initial meetings with the enrolling district and the Minnesota State Academy for the Deaf. Please sign only after you have reviewed the online course and program and understand the expectations of enrolling in online learning.

Section II: To be completed by the Minnesota State Academy for the Deaf and the student's current district online contact person. Each school should keep a copy of this form when all signatures have been secured. The enrolling district has 15 days to review the attached course syllabus and sign and submit the form to the online learning provider.

For questions, please contact onlineacademy@msa.state.mn.us

Section 1. Information to be completed by the Student and Parent or Guardian
Student Name (Last, First, M.I.)
Date of Birth

MonthDayYear
Current Grade
Student Email
example@example.com
Student Mobile phone
Please enter a valid phone number
Student Address

Street Address

Street Address Line 2

City, State ZIP codeState / Province

Postal / Zip Code
Parent 1/Guardian Name (Last, First, M.I.)
Parent 1/Guardian Mobile phone
Please enter a valid phone number
Parent 1/Guardian Address

Address (if different)

Street Address Line 2

City, State ZIP codeState / Province

Postal / Zip Code
Parent 1/Guardian Email
example@example.com
Parent 1/Guardian Contact Preference

Phone CallTextEmail
Parent 2/Guardian Name (Last, First, M.I.)
Parent 2/Guardian Mobile phone
Please enter a valid phone number
Parent 2/Guardian Address

Address (if different)

Street Address Line 2

City, State ZIP codeState / Province

Postal / Zip Code
Parent 2/Guardian Email
example@example.com
Parent 2/Guardian Contact Preference

Phone CallTextEmail
MSAD Online Course(s) Registration Request
School Currently Enrolled at
Met with (name)
Date

MonthDayYear
Term
Date submitted

MonthDayYear
More than 50% of the student's schedule?

YesNo
Online Course Name #1
Replaces local course name #1
Online Course Name #2
Replaces local course name #2
Does the student have an current IEP?

YesNo
Special Education Case Manager Name
Email address of Case Manager
example@example.com
Phone Number of Case Manager
I have discussed supplemental online course enrollment with my enrolling school representative indicated above. I have reviewed the online course(s) registration request and understand the expectations of enrolling in supplemental online courses.
Student Signature (required) - please sign in box below

Clear
Date

MonthDayYear
Parent/guardian signature required for students under 18 years old.
Parent/guardian Signature - please sign in box below

Clear
Print name and relationship
STOP HERE and SUBMIT FORM
SECTION II: Supplemental Course Registration to be completed by Minnesota State Academy for the Deaf.
Program Name
Phone Number
Please enter a valid phone number
Fax Number
Online Learning Program Coordinator
Email address
example@example.com
Oneline Learning Program Mailing Address

Street Address

Street Address Line 2

City, State, ZIP codeState / Province

Postal / Zip Code
Enrolling School
District Number
District Type
Site Number
Enrolling school Phone Number
Please enter a valid phone number
Enrolling School Fax Number
Enrolling School Contact Person or Counselor
Email address of Contact Person
example@example.com
Enrolling School Address

Street Address

Street Address Line 2

City, State, ZIP codeState / Province

Postal / Zip Code
OLL proposed plan for: Student name
Student MARSS Number
Online Course #1
Credit Recovery
Start Date
Sem/Tri/Qtr
Credits
Proposed completion date:
Meets enrolling district's graduation requirement. Enter "X" and initial:
Online Course #2
Credit Recovery
Start Date
Sem/Tri/Qtr
Credits
Proposed completion date
Meets enrolling district's graduation requirement. Enter "X" and initial:
To be completed by the enrolling district:
Select one of the following:

The coursework will substitute for other course work in the enrolling district and will be funded by the normal funding formula for online learning.This coursework will substitute for other course work in the enrolling distract and will be funded by a contractual agreement with the enrolling district.This coursework is being taken in addition to the regular district course work and the tuition will be paid by the student.This is a private, non-resident or homeschool student and will pay tuition for which they will be billed.This is an extended time course to support students who are at risk for not grade progressing in the enrolling district and will be funded based on Minnesota Statutes, section 124D.68.
Check all the apply:

Enrolling district waives the 15 day deadline for enrollmentEnrolling district waives 50% online learning credit limit.The student is receiving ELL servicesThe student qualifies as homeless/highly mobile
I have shared the online learning course(s) sylllabus with the enrolling district contact person.
Signature of OLL provider contact person - please sign in box below:

Clear
Print name and title
Date

MonthDayYear
Date
Please submit to enrolling district contact person.

I have reviewed the course syllabus and the course(s) checked meet the enrolling district's graduation requirements.
Signature of enrolling district online learning contact person

Clear
Print name and title
Date notification received

MonthDayYear
Date
Date

MonthDayYear
Date
Schedule changes may not be made after the midpoint of enrolling district's term unless waived by both schools.

Attention: Upon completion submit this form to the online learning provider in section II.
Should be Empty:

SECTION II: Supplemental Course Registration to be completed by Minnesota State Academy for the Deaf.

To be completed by the enrolling district: