File:__LA-E & IGDH-E__

VIGO COUNTY SCHOOL CORPORATION

REQUEST FOR STUDENT PARTICIPATION IN A COMMUNITY ACTIVITY

TO: SCHOOL SERVICES/CURRICULUM ASSISTANT

FROM: ______________________________________ __________________________________

(Name) (Position)

______________________________________ __________________________________

(Address) (Phone Number)

SUBJECT: ___________________________________________________________________________

(Nature of Request)

1. Grade Levels Involved: _____________________________________

2. Number of Pupils: _____________________________________

3. Names of Schools: _______________________________________________________

_______________________________________________________

4. Amount of Pupil Time: Daily Basis_______________ Cumulative Basis____________

5. Starting Date: _____________________________________

6. Completion Date: _____________________________________

7. Responsibilities of: (Please explain briefly)

a. Teacher

b. Principal

c. Investigator

d. Pupils

8. Brief Summary of Requested Activity:_____________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

9. Attach one copy of the complete research proposal

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FOR VIGO COUNTY SCHOOL COPORATION USE ONLY DATE_________________________

Recommendation of Review Committee:

PROJECT

Committee Members Approved Denied Additional Information Needed

___________________________ ________ ______ ________________________________

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