2601 S 35th Street, Suite 100
Tacoma, WA 98409
Ph: 866-992-5505
Fax: 855-278-8928
http://wava.k12start.com
http://iswa.k12start.com
LEARNING COACH WAIVER FORM
2015-2016 School Year
2015-2016 School Year
Learning Coach/Adult Student (18+) Waiver Form
Student Name: ____________________________________ Grade 15-16: _________ Birthdate: ________________
Parent/Guardian Name: _______________________________________ Cell Phone: _______________________
Address: _________________________________ City: _______________________________ Zip: ___________
Assigned Learning Coach/Liaison Name: _____________________________________________________________
Assigned Learning Coach/Liaison Email Address: _____________________________ Cell Phone: ______________
LEGAL GUARDIAN’S CONSENT TO LEARNING COACH
I _________________________________ give permission and consent for ______________________________ to
Legal Guardian/Adult Student
Assigned Learning Coach/Liaison
be the learning coach and liaison for __________________________ . All conversations and requests may be
Student Name
discussed with the Learning Coach/Liaison I have assigned. The Learning Coach/Liaison ______________________________
Assigned Learning Coach/Liaison
I have assigned is the main point of contact for _________________________________in regards to any questions or concerns
Student Name
with ___________________________ education for the 2015-2016 school year. I understand and agree that all documents
Student Name
Legal Guardian/Adult Student signature will be signed by myself. I also understand and agree that I, the Legal Guardian/Adult
Student must comply with monthly contacts with the teacher(s) as scheduled regarding my student.
________________________________________________________
Legal Guardian/Adult Student Signature
____________________________
Date
LEARNING COACH’S COMMITMENT
I, __________________________________ , as the requested and assigned Learning Coach/Liaison do agree to be
Assigned Learning Coach/Liaison
Main point of contact for _________________________________ regarding school work, grades, or any
information requested on my behalf.
Student Name
_________________________________________________________
Assigned Learning Coach/Liaison Signature
____________________________
Date