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*Retake Form

*Note:  There's a printable PDF form of the retake form available on the bottom of this page.

Retake Request Form


Student’s Name: ______________________________  

Date: _____________________

Activity Title: _________________________________

Date of Activity: ____________

Your Score: _________________                           

Goal for retake:  ________________


Please state the reason you would like to retake this activity:




What did you do to prepare initially?

What will you do to prepare for the retake?












1.  I understand the purpose of a retake is to improve my knowledge and skills and I agree to take the responsibility to prepare myself.

2.  I have read and understand the policy for retakes printed on the back of this page.



Student Signature _____________________    

Parent Signature_____________________



Policy for Retakes


·      Only forms completely filled out will be accepted.

·      A different activity assessing the standard(s) may be provided.

·      The higher  score earned will be recorded.

·      A student’s request may be declined at the teacher’s discretion.


Students must:

·      Make the request on the appropriate form.

·      Fill out the entire form.

·      Turn in the form within three days of receiving the grade.

·      Obtain a parent signature on the retake form.

·      Retake the activity within one week from the return of the original.  Date will be determined between the teacher and student.

·      Retake the activity before or after school on the designated day.


Retake scheduled date/time:   ___________________________________

Original score:  __________________

Retake score:  ___________________


Lisa B,
Aug 21, 2018, 12:14 PM