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Independent Study Project Initial Proposal Request Form
Independent Study
Independent Study Project Initial Proposal Request Form
Independent Study Project Initial Proposal Request Form

Independent Study is a school-approved, student-centered, alternative method of learning that allows a student to
Independent while working on a Initial Proposal Request Form earn regular education course creditStudy Project standards-based, curriculum-aligned, independent project.
Independent Study
Independent Study work independently according to the plan outlined below, but will remain under the
 A student will
Independent Study is a of a certified teacher.
Independent supervision school-approved, student-centered, alternative method of learning that allows a student to
Study a school-approved, student-centered, alternative method of learning that allows a student to
IndependentisStudy
earn regular education course can be used on a short-term or long-term basis, either in combination with their regular
 education course credit while working on a standards-based, curriculum-aligned, independent project. earn regular Independent Studycredit while working on a standards-based, curriculum-aligned, independent project. student is work independently according to the plan outlined below, but will remain under the
Independent Study willor as an isolated project.
  AAcourse loada school-approved, student-centered, alternative method of but will remain under the student will work independently according to the plan outlined below, learning that allows a student to earn regular educationaStudy projects must equate in quality and quantitycurriculum-aligned, independent project.
supervision ofcourse credit while working on a standards-based, to regular education courses delivered by
Independent a certified teacher. supervision of certified teacher.
Connections work be
Independent Study can be used on short-term to the plan outlined below, in combination under the
A student Study canindependently short-term or long-term basis, either combination with their regular
 IndependentwillAcademy. used on a a according or long-term basis, either inbut will remainwith their regular supervision asa an courses are graded courses (using the school’s A–F grading scale).
course load or as certified teacher.
Independent an isolated project. course load orofStudyisolated project.
Independent Study projects must equate in quality and quantitybasis, either education courses delivered by
Independent Study projectsused on a short-term or and quantity to regular in combination with their regular
Independent Study can be must equate in quality long-term to regular education courses delivered by

Connections or as an isolated project. course load Academy.
Connections Academy.
Independent Study courses are graded courses (usingand quantity toA–F grading scale).
Independent Study courses are graded courses (using the school’s regular education courses delivered by
 Independent Study projects must equate in quality the school’s A–F grading scale).
Approval Process
Connections Academy.
 Independent complete an Independent Study course for credit must complete the following steps:
A student wishing to Study courses are graded courses (using the school’s A–F grading scale).
1. Meet with the
ApprovalProcess school counselor to generally review the Independent Study project concept.
Process
ApprovalObtain counselor’s initial approval to proceed with the planning.
2.
3. Complete this
AA student wishing to complete an Independent Study form, and credit must complete the following steps: assistance). student wishing to complete an Independent Study course for credit it to complete the following steps:
Approval ProcessIndependent Study requestcourse for submit mustthe counselor (requires teacher
Obtain the school counselor to generally review the Independent Study project concept.
1. Meet with official counselor approval.
1. 4. Meet with the school counselor to generally review the Independent Study project concept.
5. Obtain theto completetheapproval to proceed course the planning. complete the following steps:
Start counselor’s initial approval to Study with the planning.
2.
A student wishing course per an Independent proceed with thiscredit must
2. Obtain counselor’s initial specifications outlined on for plan.
3. Complete this Independent Study request form, and the Independent Study project concept. assistance).
Meet with the school counselor request form, and submit it to the counselor (requires teacher
3. 1. Complete this Independent Study to generally review submit it to the counselor (requires teacher assistance).
4. Obtain official counselor approval. to proceed with the planning.
2. Obtain official counselor approval.
Obtain counselor’s initial approval
4.
5. Start the course per the specifications outlined on and submit it to the counselor (requires teacher assistance).
Start the courseIndependent Study request form, this plan.
5. 3. Complete this per the specifications outlined on this plan.
Course and Section Information
4. Obtain official counselor approval.
5. Start the course per the specifications outlined on this plan.
Student’s Last Name

Student’s First Name

Jennifer Henderson

Independent Study-Physical Education

Course and Section Information
Course and Section Information
Supervising
CourseLast Teacher’s Name Information
Student’s and Section
Name
Student’s Last Name

2/6/2012
Jennifer Henderson
Jennifer Henderson
Student’s Last Name

6/15/2012

Start Date of Course/Section
Supervising Teacher’s Name
Supervising Teacher’s Name

Jennifer Henderson
General Description of the
2/6/2012 Study Course:
Independent
2/6/2012 Teacher’s Name
Supervising

Course Name
Student’s First Name
Student’s First Name

End Date of Course/Section

6/15/2012
6/15/2012

Student’s Middle Name

0.5

Number of
Student’s Middle Name
Student’s Middle Name
Credits

Independent Study-Physical Education 0.5
Independent Study-Physical Education Middle Name
Student’s First Name
Student’s 0.5
Course Name
Course Name

Number
Number ofof

Credits
Independent Study-Physical Education Credits
0.5

Course Name
Number of
Start Date Course/Section
End Date Course/Section
Credits
Start Date ofof Course/Section
End Date ofof Course/Section
Student’s Rationale for
6/15/2012
2/6/2012
General Description of the
Permission Course/Section
GeneralDate of to Complete This
Start Description of the
End Date of Course/Section
Independent Study Course:
Course:
Independent Study Course:
General Description of the
Independent Study Project Initial Proposal Request Form
Student’s Rationale for
Student’sCourses/sections may not last longer than a given school year (per the school’s calendar).
Independent Study Course:
Note: Rationale for This
Permission Complete This
Permission toto Complete
Course:
Course:
Student’s Goals
Course Rationale forcourses will count towards the overall graduation requirements, but will not fulfill the schools’
IndependentComplete This
Permission to Study
The student should workmay not last longer than a given school year (per the school’s calendar). Independent specific subject requirements.last longer than a teacher to properly complete this section. List
Note: Courses/sections with his/her supervising given school year (per the school’s calendar). this
Course:
Note: Courses/sections may not

Study course’s major goals/objectives.

Note: Courses/sections may not last towards the given graduation (per the school’s will not fulfill the schools’
Independent Study courses will countlonger the aoverallschool year requirements, but calendar).
Independent Study courses will count towardsthan overall graduation requirements, but will not fulfill the schools’
1.
specific subject requirements. specific subject requirements.
2.
Independent Study courses will count towards the overall graduation requirements, but will not fulfill the schools’
3.
specific subject requirements.
4.
© 2007 Connections Academy®, LLC.
Questions? Call 1-800-382-6010. www.connectionsacademy.com ®
©© 2007 Connections Academy , LLC.
2007 Connections Academy® , LLC.

Required Assignments

Questions? Call 1-800-382-6010.
Questions? Call 1-800-382-6010.

www.connectionsacademy.com www.connectionsacademy.com The student should work with his/her supervising teacher to Call 1-800-382-6010.this section. Specifically list the
© 2007 Connections Academy®, LLC.
Questions? properly complete www.connectionsacademy.com student’s required assignments for this course.
Assignment Type
1. Daily Assignments
Weekly Updates

Assignment Description
The student will complete a written update weekly for the supervising teacher.

Resources

List all resources to be utilized in order to meet the course goals and complete the required assignments.

Independent Study Project Initial Proposal Request Form
Independent Study
Schedule

Independent Study Project Initial Proposal Request Form

Independent Study is a school-approved, student-centered, alternative method of learning that allows a student to
Evaluation
The student will work on this course on working basis during the specified time period outlined on this project. earn regular education course credit while a regular on a standards-based, curriculum-aligned, independentplan.
Independent Study lessons will appear on the student’s planner once a week and but student will under the these
 A student will work independently according to the plan outlined below, the will remain check off
The teacher will evaluate each assignment listed work. lessons supervisionthe a certified teacher. week’sabove, and the student’s effort and participation during the course. to indicate of completion of each
The teacher will enter a final grade intoon a student’s grade book viabasis, either in Project Initial Proposal Request Form
Independent Study combination with their regular
 Independent Study can be used the short-term or long-term one large portfolio assignment. That uploaded portfolio assignment willan isolated project. each assignment separately, but just one overall summary grade will specifically evaluate course load or as be recorded in the grade book.
 Independent Study projects must equate in quality and quantity to regular education courses delivered by
Evaluation
Connections Academy.
 Independent Study courses are graded courses (using the school’s A–F grading scale).
The teacher will evaluate each assignment listed above, and the student’s effort and participation during the course.
The teacher will enter a final grade into the student’s grade book via one large portfolio assignment. That uploaded
Roles and Responsibilities portfolio assignment will specifically evaluate each assignment separately, but just outlined below:
Expected responsibilities of each participant of this Independent Study project are one overall summary grade will be recorded in the grade
Approval Process book.
Page 2 of 4
Student: The student is responsible for taking the initiative to complete this course, and will complete the
A student wishing to complete manner in order Study course for credit must complete the must commit the same an Independent to meet the established goals. The student following steps: assigned tasks in a timely
1. Connections Academy counselor to as he Questions? Call 1-800-382-6010.
©amount of time and school®, LLC.coursegenerallyshe doesthe Independent Study project concept.
2007Meet with the effort to this www.connectionsacademy.com or review with other courses.
2. Obtain Responsibilities counselor’s initial approval to proceed with the planning.
Roles and
3. Complete this Independent Study request form, and submit it to course goals (requires teacher assistance).
Supervising Teacher: The teacher will help this Independent Study the counselor and assignments, and will be
Expected responsibilities of each participant of the student establish theproject are outlined below:
4. Obtain questions and consultation available forofficial counselor approval. throughout the project. The teacher will also ensure that the student is
5. Start the student is the specifications outlined on this and
Student: The course perresponsible(completing assignmentsto complete this course, and will complete and is consistently working on the course for taking the initiativeplan. checking off lessons on the planner), the assignedprogress towards the pre-established goals.the established goals.will evaluate must commit final products, making tasks in a timely manner in order to meet Finally, the teacher The student the student’s the same amount of time and effort to this student’s grade book. with other courses. and will enter evaluations in the course as he or she does

Course and Section Information

Supervising Teacher: The teacher will help the student establish thethat the goals and assignments, and will be
Parent/Learning Coach: The parent or Learning Coach will ensure course student has the resources and available for questions and consultation throughout will project. The that the student isensure that the student the materials needed to complete the course. He or she the also ensure teacher will also consistently applying is
Student’sand attention that the course requires in order to complete the assignments and accomplish the goals. is
Student’s First Name
Student’s Middle Name consistently working on the course (completing assignments and checking off lessons on the planner), and effort Last Name making Henderson
Independent Study-Physical Education 0.5
Jennifer progress towards the pre-established goals. Finally, the teacher will evaluate the student’s final products, and will enter evaluations in the student’s grade book.
Counselor/Principal: The school counselor (or principal) will approve the course, help the student set it up, and
Supervising Teacher’s Name
Course Name
Number of will coordinate efforts between the teacher and the student. The counselor will also help the student incorporate
Credits
Parent/Learning overall The parent or Learning toward graduation. the course
6/15/2012
2/6/2012 into an Coach:course of study and planCoach will ensure that the student has the resources and materials needed to complete the course. He or she will also ensure that the student is consistently applying the
Start Date of Course/Section
End Date of Course/Section effort and attention that the course requires in order to complete the assignments and accomplish the goals.
General Description of the
Independent Study Course:

Counselor/Principal: The school counselor (or principal) will approve the course, help the student set it up, and

Participant Approvals and Authorization will coordinate efforts between the teacher and the student. The counselor will also help the student incorporate
Student’s Rationale for

Bythe course Completeoverall course of study and plan toward graduation. checking into an am
Permission to below, I This acknowledging my approval for the implementation of this Independent Study project for this student. I also agree to participate as required by my defined role (above) to the best of my abilities.
Course:
Parent/Legal Guardian (Caretaker) than a given school year (per
Date:
Note: Courses/sections may not last longerAcknowledgement (PLCA) the school’s calendar).
Student Agreement
Date:
Participant Approvals and Authorization graduation requirements, but will not fulfill the schools’
Supervising Teacher Agreement
Date:
Independent Study courses will count towards the overall
By checking below, I am acknowledging my approval for the implementation of this Independent Study project for specific subject requirements. this student. I also agree to participate as required by my defined role (above) to the best of my abilities.
Parent/Legal Guardian (Caretaker) Acknowledgement (PLCA)
Student Agreement
Supervising Teacher Agreement

© 2007 Connections Academy®, LLC.

Questions? Call 1-800-382-6010.
Page 3 of 4

Date:
Date:
Date: www.connectionsacademy.com

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