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New Jerusalem Elementary School District
Request for Retention
California Assembly Bill 104 provides a process for parents and guardians to request that their student repeat the grade they were enrolled in during the 2020-2021 school year. Parents and guardians of students who were in grades Kindergarten - 11 in the last school year are eligible to make this request if their student received a "Not Met", D, F, I, or NM grade for at least one-half of their coursework in the 2020-2021 school year
Please complete and submit this form for any request for retention. It will be sent to your School Site Principal. You will be contacted to arrange a consultation time with your child's principal, teacher, and/or counselor.
Solicitud de Retención
El Proyecto de Ley 104 de la Asamblea de California proporciona un proceso para que los padres y tutores soliciten que su estudiante repita el grado en el que estaba inscrito durante el año escolar 2020-2021. Los padres y tutores de estudiantes que estaban en los grados Kindergarten - 11 en el último año escolar son elegibles para hacer esta solicitud si su estudiante recibió una calificación de "No Cumplido", D, F, I o NM durante al menos la mitad de su cursos en el año escolar 2020-2021
Complete y envíe este formulario para cualquier solicitud de retención. La solicitud se enviará al director de su escuela. Nos comunicaremos con usted para concertar una consulta con el director, el maestro y / o el consejero de su hijo.
Student Name
Nombre del Estudiante
*
First
Last
Date of Birth
Fecha de Nacimiento
*
MM
/
DD
/
YYYY
Requesting to retain student in grade
Grado en el cual se solicita retener el estudiante
*
TK
KN
1
2
3
4
5
6
7
8
9
10
11
2020-2021 School
Escuela durante el ano 2020-2021
*
New Jerusalem Elementary
Delta K8
Delta Charter High School
Does your student receive Special Education services?
Su estudiante recibe servicios de Educacion Especial?
*
Yes
No
Does your student receive services through a 504 Plan?
Su estudiante recive servicios por medio de un Plan 504?
Yes
No
Parent/Guardian Name
Nombre del Padre / Guardian
*
First
Last
2nd Parent/Guardian Name
Nombre del 2ndo Padre / Guardian
First
Last
Street Address
Direccion
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
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United Republic of Tanzania
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Country / Region
Phone
Numero de Telefono
###
-
###
-
####
Phone
Numero de Telefono
###
-
###
-
####
Email
Correo Electronico
Reason for request
Razon por solicitud
*