For the table below, only fill in areas where there are changes. Pilot schools
planning to change one or more Pupil-Free Days and/or make changes to
their instructional calendar must consider the impact of the requested
change prior to submitting this form. Please review the School Calendar
section in the Pilot Manual for guidance using the attached planning
guidelines. Calendar change requests before Board adoption of District
calendar and final furlough agreements with labor partners (if applicable)
are considered tentative and subject to revisions.
Please send completed forms to your LD Administrator of Operations and
Instructional Director by March 12, 2021. No FAXES will be accepted.The
Administrator of Operations will e-mail the signed form to the central offices
for for an assessment of operational and fiscal impact. If Central Office
projects costs will be associated with the proposed changes, the LD AO will
notify the Principal and the instructional director. Once all reviews and
applicable modifications/revisions are completed, a confirmation e-mail will be
sent to the Principal by the LDAO by April 23, 2021.
We are following the District’s Single Track Calendar except as noted in the table below.
School Name (Required)
Location Code (Required)
Contact Person:
Phone / E-mail Address:
First Day of Instrcution
Winter Break
Last Day of Instruction
Spring Break
Pupil Free Days
Change FROM:
Change TO:
Legal Holidays
School Holidays
Other days not in
Total Number of
Instructional Days
I certify that (please check as it applies):
the number of required annual instructional minutes and instructional days will be met
the number of employee paid work days are in accordance with basis requirements and applicable furlough Days
Please use Attachment A-2 to describe how you are addressing any Operational and/or Fiscal Impact to the changes in your school’s
instructional calendar.
PRINCIPAL (Signature)
2021-2022 (SCHOOL YEAR)