PART I—To be completed by the student and parent/guardian and submitted to the counseling office when a program requiring less
than full-time daily attendance is requested and will provide an effective educational experience for the student.
Student’s Name __________________________________ MCPS ID#__________ Grade ____ School_________________________________
Home Address
_____________________________________________________________________________________ Phone ____-____-_____
Reason for request
_____________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
We, the undersigned, understand that if part-time secondary schedule is approved, the student will be permitted to only attend and
participate in the courses listed below, and will only receive credit or grades for the courses listed. We understand this may impact
scheduled completion of graduation requirements.
Signature, Student/Eligible Student
____________________________________________________________________Date____/____/_____
Signature, Parent/Guardian
___________________________________________________________________________ Date____/____/_____
PART II—To be completed by the student’s school counselor and submitted to the principal.
Does the student have an IEP or a Section 504 Plan? o Yes* o No
*
If yes, contact the cluster supervisor (for students with an IEP). For students with a Section 504 Plan, contact the school Section 504 coordinator or the Section 504 case
manager. The cluster supervisor or Section 504 coordinator/case manager will consult with the Resolution and Compliance Unit (RACU) and all completed copies of this
form for students with disabilities must be forwarded to the supervisor of RACU. Transportation arrangements for students with disabilities will be reviewed by RACU.
o Recommend approval o Recommend disapproval
Enter Subjects for Each Period Scheduled
1 2 3 4 5 6 7 8
Reason for recommendation ____________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Signature, School Counselor___________________________________________________________________________Date____/____/_____
PART III—To be completed by principal/designee and returned to the student and parent/guardian
The request for authorization to attend school on a part-time daily schedule is:
o
Approved* o Disapproved for the following reason ____________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Signature, Principal/Designee
__________________________________________________________________________Date____/____/_____
* If approved, the student must be registered as a full-time resident student.
DISTRIBUTION: ORIGINAL/Student’s file; COPY 1/Student/Parent/Guardian; COPY 2/Principal; COPY 3/Attendance/Secretary
Request for Approval for Part-Time Secondary Schedule
Office of Student and Family Support and Engagement
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
See MCPS Regulation IHC-RA, Part-time Daily Attendance for Secondary Students
MCPS Form 280-98
August 2020
