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NORWALK-LA MIRADA UNIFIED SCHOOL DISTRICT ALTERNATIVE PROGRAMS &

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NORWALK-LA MIRADA UNIFIED SCHOOL DISTRICT
ALTERNATIVE PROGRAMS & SERVICES APPLICATION
Program Request:
Independent Study 9-12 Virtual Program K-12
Independent Study K-8 Home/Hospital Teaching
El Camino High School (Continuation)
Student Name: Student ID #: Grade:
Address: Age: DOB:
City: Zip Code: Home Phone #:
Student Email: Student Cell #:
Parent/Guardian Name: Parent Work #:
Parent/Guardian Email: Parent Cell #:
School of Residence: School Currently Attending:
Reason for Alternative Education Placement Request:
Anticipated Duration of Alternative Education Placement if Approved:
Overall GPA
Total Credits
Parent/Guardian (Print/Sign) Date ELD Level
504 Y/N
Student (Print/Sign) Date
SART/SARB Y/N
Referring Counselor (Print/Sign) Date SPED Y/N
Other Prog
Principal/Designee (Print/Sign) Date 7/2020
Home School Use Only
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NORWALK-LA MIRADA UNIFIED SCHOOL DISTRICT ALTERNATIVE PROGRAMS &

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Completed 9 March 2021

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