Information Change Request

Student(s) Full Name (If more than one student separate by comma )

Student(s) Full Legal First & Last Name

Student Grade Level*

Do you have another student account to update?*

YesNo

Student Full Name (only enter one name)*

Student Full Legal First & Last Name

Student Grade Level*

Do you have another student account to update?*

YesNo

Student Full Name (only enter one name)*

Student Full Legal First & Last Name

Student Grade Level*

Do you have another student account to update?*

YesNo

Student Full Name (only enter one name)*

Student Full Legal First & Last Name

Student Grade Level*

Do you have another student account to update?*

YesNo

Student Full Name (only enter one name)*

Student Full Legal First & Last Name

Student Grade Level*

Do you have another student account to update?*

YesNo

Student Full Name (only enter one name)*

Student Full Legal First & Last Name

Student Grade Level*

Are you changing/adding a Learning Coach?*

YesNo

Are you changing an address for a student?*

YesNo

Are you changing an address for a Legal Guardian/Parent?*

YesNo

Are you changing a phone number?*

YesNo

Are you changing an email address?*

YesNo

The LC (Learning Coach) is the primary adult working with your student at home.

If multiple learning coaches are assigned the system can not guarantee which LC will receive our emailed communication.

Learning Coach (LC) Name:*

LC Relationship to student:

LC Home Address:*

LC Home Phone:*

LC Alternate Phone:

LC Email:*

example@example.com

Are you adding an additional LC or replacing the current one?

Replace the currently assigned LC with the person listed above.Add the person listed above as an additional LC. I have read and understand there is not a systematic way to ensure one LC or the other, or both receive all communication. The LC's will communicate with each other.

FOR ADDRESSES: YOU WILL NEED TO PROVIDE A NEW PROOF OF RESIDENCY DOCUMENT to update any addresses. Any student or Legal Guardian/Parent address change will automatically update for physical, shipping, and mailing addresses.

New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select which New Proof of Residency you will attach.

Who's Phone Number is being updated?

New Phone Number

Please enter a valid phone number.

Who's Email Address is being updated?

Email

example@example.com

Please type ANY additional notes that will help us complete your request:

I certify that I am the legal guardian for the above student(s) and I am signing in acknowledgement that the above changes will be made for the named students. If the student is over the age of 18 the student is their own legal guardian.*

Yes

Name of person completing this form:*

First NameLast Name

Phone Number (If there are questions about this form)*

Please enter a valid phone number.

Email of Legal Guardian completing this form:*

example@example.com

Signature*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code