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REQUEST FOR AFTER SCHOOL VIRTUAL COURSE(S)

STUDENT INFORMATION: (Please print all information) _________________________ ______________________ _____ _________________ __________ LAST NAME FIRST NAME MI STUDENT ID# GRADE ______________________________________________ NAME OF CURRENT SCHOOL OF ENROLLMENT
I would like to take a virtual course offered through Duval Virtual Instruction Academy in addition to my current class load. If approved, I understand that the course(s) must be completed by the end of the current semester/school year (as appropriate) in order to be awarded credit. I also understand I will be withdrawn from the course if I do not participate by submitting work on a weekly basis. Withdrawal from the course prior to completion will result in a grade of F.

__________________________________ STUDENT SIGNATURE PARENT/GUARDIAN APPROVAL:

_______________________________ DATE

I would like for my child to take a virtual course offered through Duval Virtual Instruction Academy in addition to his/her current class load. If approved, I understand that the course(s) must be completed by the end of the current semester/school year (as appropriate) in order to be awarded credit. I also understand I will be withdrawn from the course if I do not participate by submitting work on a weekly basis. Withdrawal from the course prior to completion will result in a grade of F.

_________________________________ PARENT/GUARDIAN SIGNATURE

_________________________________ DATE

TO BE COMPLETED BY SCHOOL GUIDANCE COUNSELOR: COUNSELOR INFORMATION: _______________________ _______________________ Print Name SIGNATURE Provide the course title and ID# then select Yes or No to indicated counselor approval and initial. COURSE TITLE COURSE ID # COUNSELOR INITIALS ____________________________ _________________________ ____________________________ _________________________ YES / NO ________________ YES/NO ________________

ADMINISTRATIVE APPROVAL: Submit to school Principal or designee for approval and entering school 7006 as 2nd School of Enrollment for the student. Once complete, fax to DAWN ELKINS 904-390-2075. _________________________________ PRINCIPAL/DESIGNEE SIGNATURE *Incomplete requests will not be processed _________ DATE
CRT/DATA ENTRY ENTER 7006 AS 2ND SCHOOL OF ENROLLMENT AND INITIAL AFTER COMPLETE. _________________ CRT INITIALS _________________ DATE

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