Virtual Education Program Consent Form
Please complete this form to provide consent for participation in the virtual education program.
Student's Full Name
*
First Name
Last Name
Student's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade/Year Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
High School (9-12)
Other
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Virtual Program
*
Program Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Program End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
By signing below, I confirm that I am the parent or legal guardian of the student named above, and I give permission for their participation in the virtual education program. I acknowledge that I have read and understood the program details, requirements for online participation, and agree to the terms stated above.
*
Submit Consent
Submit Consent
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