Temporary Independent Study Assignment Form
Child’s Name __________________________ Class _______ Month ____________________
This assignment form is in addition to the Master Agreement. Assignment begins on the first home school day of the month and must be completed by the last day of the month. Turn in this form with completed assignments at your child’s classroom as requested or no later than the first day school of the following month.
Projected independent study days. _____ Teacher signature____________________ Date ___________
I
certify that the work listed below was completed by my child on the home study
days checked below.
Fill
in dates for each day during this temporary independent study period. If just
one day, fill in just that date.
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Parent Signature _____________________________ Date form turned in: ___________
Assignments: Work Completed:
Teacher Certification
My signature and date on the work product are evidence that I, as the assigned supervising teacher, have personally evaluated the pupil’s work for both academic and apportionment credit.
______Independent Study Days credit earned.
Worked assessed as: excellent satisfactory poor
Teacher Signature ___________________________________ Date __________________
+++ The School work attached represents one day’s independent study attendance credit..