Policy 2470F - Self-Directed Learner Application Form

2470F: Self-Directed Learner Application Form 
Self-Directed Learner (SDL) Application & Postsecondary/Personal Goals Plan 

 

Student Name: _________________________________________ 
Grade Level: ___________ 
Date of Plan Submission: ___________ 

Application Initiated By: _______________________________ 
☐ Student  ☐ Parent/Guardian  ☐ Teacher 
Relationship to Student: _______________________________ 

Members in Attendance (for Plan Development/Approval): 

  • Student: ______________________ 
  • Parent(s)/Guardian(s): ______________________ 
  • Teacher(s): ______________________ 
  • Administrator/Designee: ______________________ 

 

SECTION 1 — Eligibility Criteria 

To be designated as a Self-Directed Learner, the student must meet one or more of the following criteria: 

1. Mastery of Content Knowledge 

Demonstrate mastery of all core subjects/classes at their grade level through: 
 
☐ Most recent report card or progress report showing grades of at least 70% in each core subject  
     and/or GPA ≥ 2.0 
☐ Most recent NWEA MAP or ISAT results showing overall academic growth 
☐ Mastery-based learning portfolio approved by administration 
 

2. Timeliness, Motivation, and Goal-Setting 

  • Ability to submit assignments on time, demonstrate self-motivation, and set/achieve attainable goals 
  • Teacher attestation required in Section 5 

3. Basic Math Mastery (Grades 5+) (Must meet one of the following requirements.) 

  • Demonstrate mastery of addition and multiplication (0–10) and related subtraction/division facts 
  • Assessed via the RISE Basic Math Assessment 

4. Postsecondary Career & Education Goals (Grades 8+) 

  • Completion of an official Career Pathway / Student Learning Plan, kept up to date 
  • Evidence of progress toward postsecondary goals through: 
  • Extended Learning Opportunities (ELO) 
  • Advanced Opportunities 
  • Challenging coursework (Policy 2435) 
  • Successful completion of online courses or college credit 

5. Personal Life Goals (Grades 8+) 

Students must provide a written description of their self-determined personal life goals, including: 

  1. A statement of their personal life goals 
  2. An explanation of how attending specific classes or participating in learning activities will help achieve these personal goals in addition to postsecondary/career goals 

Attach a document or write below: 

 

 

 

6. Additional Considerations 

  • Any special circumstances (IEP, 504, EL, Migrant, McKinney-Vento, GT, etc.): 

 

 

SECTION 2 — Flexibility Requested 

Describe the flexible learning accommodations requested: 

  1. Requested Exemptions: 

 

  1. Supervision Plan (if outside classroom): 

 

  1. How Flexibility Supports Learning and Goals (Grade 8+ includes postsecondary and personal goals): 

 

Optional Flexible Learning Options: 
☐ Flexible attendance 
☐ Virtual attendance 
☐ Extended learning opportunities 
☐ Curriculum compacting / acceleration / credit by exam 
☐ Other: ___________________________ 

Attach separate documentation if needed. 

 

SECTION 3 — Requirements to Maintain SDL Status 

To maintain Self-Directed Learner status, the student agrees to: 

  1. Continue to master grade-level knowledge and skills and demonstrate academic growth 
  2. Comply with school conduct rules (except any exemptions granted) 
  3. Submit quarterly updates outlining: 
  • Planned instructional flexibility 
  • Progress toward grade-level content mastery 
  • Progress toward postsecondary goals (Grade 8+) 
  • Progress toward personal life goals (Grade 8+) 

 

SECTION 4 — Review & Rescission 

  • SDL designation may be rescinded if the student: 
  • Fails to meet eligibility criteria 
  • Fails to complete assignments on time 
  • Does not follow the agreed-upon plan 
  • SDL designation may also be voluntarily terminated by the student/parent at the end of a quarter, semester, or school year. 
  • Plan Review Date: __________________ 
  • Rescission Date (if applicable): __________________ 
  • Administrative Signature: __________________ 

 

 

 

SECTION 5 — Signatures 

Student Acknowledgement 

I wish to be designated as a Self-Directed Learner and will strive to meet all plan requirements. 

Student Name (print): __________________________ 
Signature: __________________________ Date: _________ 

 
Parent/Guardian Permission 

I grant permission for my child to participate as a Self-Directed Learner. 

Parent/Guardian Name (print): __________________________ 
Signature: __________________________ Date: _________ 

 
Supervising Adult (if different from Parent/Guardian) 

Acknowledges responsibility for supporting the student’s SDL plan. 

Name (print): __________________________ 
Signature: __________________________ Date: _________ 

 
Teacher Recommendation 

I recommend the student be designated as a Self-Directed Learner based on mastery, growth, motivation, and goal setting. 

Teacher Name (print): __________________________ 
Signature: __________________________ Date: _________ 

 
Administrator Approval 

Administrator Name (print): __________________________ 
Signature: __________________________ Date: _________ 

 

SECTION 6 — Attachments / Supporting Documentation 

  • ☐ Career Pathway / Student Learning Plan (Grades 8+) 
  • ☐ Personal Life Goals Statement (Grades 8+) 
  • ☐ Mastery-Based Portfolio 
  • ☐ Assessment Reports (Report cards, NWEA MAP, ISAT) 
  • ☐ Other Supporting Documents: __________________________ 

 

Policy History: 

Adopted on: December 15, 2025 

Revised on: 

Reviewed on: