CORE 11 Earth Science Semester 1 CLAS 6 Sources of Energy PDF

Summary

This document is a contextualized learning activity sheet (CLAS) for Grade 11 Earth Science, focusing on sources of energy such as fossil fuels, geothermal energy, and hydroelectric energy. The document covers the formation of fossil fuels and the characteristics of coal, oil, natural gas, and associated concepts. It features questions, activities, and diagrams related to these energy sources, highlighting their uses and implications.

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Name: ____________________________________ Grade/Section: ___________________________ 11 Earth Science Semester I – Week 6 Sources of Energy CONTEXTUALIZED LEARNING ACTIVITY SHEETS SCHOOLS DIVISION OF PU...

Name: ____________________________________ Grade/Section: ___________________________ 11 Earth Science Semester I – Week 6 Sources of Energy CONTEXTUALIZED LEARNING ACTIVITY SHEETS SCHOOLS DIVISION OF PUERTO PRINCESA CITY Earth Science – Grade 11 Contextualized Learning Activity Sheets (CLAS) Semester I - Week 6: Sources of Energy First Edition, 2020 Republic Act 8293, Section 176 states that: No copyright shall subsist in any work of the Government of the Philippines. However, prior approval of the government agency or office wherein the work is created shall be necessary for the exploitation of such work for a profit. Such agency or office may, among other things, impose as a condition the payment of royalties. Borrowed materials (i.e., songs, stories, poems, pictures, photos, brand names, trademarks, etc.) included in this CLAS are owned by their respective copyright holders. Every effort has been exerted to locate and seek permission to use these materials from their respective copyright owners. The publisher and authors do not represent nor claim ownership over them. Published by the Schools Division of Puerto Princesa City Development Team of the Contextualized Learning Activity Sheets Writer: Sheryl P. Baron Content Editors: Sheryl C. Saclet and Geraldine B. Dangan Language Editor: Hazyl Joy A. Aquino Proofreader: Florence Joy V. Escubin Reviewers: Rolando A. Taha, EdD Illustrator: John Lemuel J. Noche Layout Artist: Sheryl P. Baron Management Team: Servillano A. Arzaga CESO V, SDS Loida P. Adornado, PhD, ASDS Cyril C. Serador, PhD, CID Chief Ronald S. Brillantes, EPS-LRMS Manager Rolando A. Taha, EdD, EPS-EsP Eva Joyce C. Presto, PDO II Rhea Ann A. Navilla, Librarian II Quality Assurance Team: Ronald S. Brillantes, Liezl O. Arosio, Carissa M. Calalin, Carmencita B. Daculap, Meguilito D. Campillos, Leslie O. Pulanco, and Llewelyn Anne M. Venturillo Division of Puerto Princesa City-Learning Resource Management Section (LRMS) Sta. Monica Heights, Brgy. Sta. Monica, Puerto Princesa City Telephone No.: (048) 434 9438 Email Address: [email protected] Lesson 1 Formation of Fossil Fuel MELC: Describe how fossil fuels are formed. (S11ES-ld-10) Objectives: 1. Identify the three major types of fossil fuels 2. Describe the sequence by which coal, oil, and natural gas form 3. Enumerate various uses of fossil fuels Let’s Try Directions: Read the following questions. Choose and encircle the letter that correspond to the best answer. 1. How are fossil fuels formed? A. Dead organisms are buried B. Fossil fuels are renewable, so they are man-made C. Dead organisms fall to the bottom of the floor and pressure and cementation change it into fossil fuels D. Dead organisms fall to the bottom of the floor and are covered in sediment heat and pressure turn into fossil fuels 2. What is the relationship between sedimentary rock and fossil fuels? A. Fossil fuels are formed within the sedimentary rocks B. They are both renewable resources C. They are made from pressure and heat D. They both take millions of years to form 3. Coal often forms where once there were swamps. What characteristic of swamps is important to the formation of coal? A. Abundant (large amounts) plant life C. High temperature B. Frequent rains D. Reptile predators 4. Which of the following answers describe the correct order of the formation of fossil fuels? A. Coal, plants, and animal die, sediments are deposited, pressure, and heat. B. Fossil fuels are created through the process of photosynthesis. C. Humans create fossil fuels in a lab. D. Plants and animals die, layers of sediment, pressure, heat, time, then coal or oil or natural gas 5. What is the difference between the way natural gas and oil are formed to the way coal is formed? A. Natural gas and oil are formed by decomposed plant and animal matter; coal is formed by decomposed plant matter only. B. Natural gas and oil are formed by decomposed animal matter only; coal is formed by decomposed plant and animal matter. C. Natural gas and oil are formed by decomposed plant matter only; coal is formed by decomposed animal matter only. D. Natural gas and oil are formed by decomposed animal matter only; coal is formed by decomposed plant matter only. 1 6. Which among the following is true about geothermal energy? A. It is pollution-free C. It’s non-renewable B. It requires treatment before use D. None of the above 7. Which of the following is an example of a geothermal energy source? A. Geyser C. A only B. Hot springs D. Both A and B 8. How is hydroelectric energy harnessed for human consumption? I. The water can be used to turn the blades of a turbine to generate electricity II. The potential energy is converted into kinetic energy as water flows downhill III. Water gains potential energy just before it spills over the top of a dam or flows downhill A. I, II, and III C. III, II, and I B. II, I, and III D. III, I, and II 9. What type of resources are considered finite and cannot be replenished in a short amount of time? A. All energy sources C. Nonrenewable energy B. Generation energy D. Renewable energy 10. What type of fossil fuel is used to generate gasoline, jet fuel, kerosene and can also be used to generate electricity or to power vehicles? A. Coal C. Oil B. Petroleum D. Peat Let’s Explore and Discover Fossil fuels are made from plants and animals that lived hundreds, or millions of years ago. The plants used energy from the Sun to form energy-rich carbon compounds. As the plants and animals died, their remains settled onto the ground and at the bottom of the sea. Layer upon layer of organic material was laid down. Eventually, the layers were buried very deeply. They experienced intense heat and pressure. Over millions of years, the organic material turned into fossil fuels. Fossil fuels are compounds of carbon and hydrogen, called hydrocarbons (Figure below). Hydrocarbons are made of carbon and hydrogen atoms. This molecule with one carbon and four hydrogen atoms is methane. Hydrocarbons can be solid, liquid, or gas. The solid form is coal. The liquid form is petroleum, or crude oil. The gaseous form is natural gas. (Source: CK- 12 Earth Science For Middle School, Fossil Fuel Formation, https://flexbooks.ck12.org/cbook/ck-12-middle-school-earth-science-flexbook- 2.0/section/20.5/primary/lesson/fossil-fuel-formation-ms-es) 2 Fossil Fuels Renewable Energy Sources Coal Biomass (burning of wood, biofuels such as ethanol & biodiesel) Oil (or petroleum) Hydroelectric power Natural gas Solar energy Other Wind energy -Oil shale Tidal and wave energy -Oil sands and tar Geothermal energy sands -Shale gas Coal Coal is a combustible black or brownish-black sedimentary rock usually occurring in rock strata in layers or veins called coal beds or coal seams. The harder forms, such as anthracite coal, can be regarded as metamorphic rock because of later exposure to elevated temperature and pressure. Coal is composed primarily of carbon along with variable quantities of other elements, chiefly hydrogen, sulfur, oxygen, and nitrogen. (Source: Catherine Abon, Earth Science Teaching Guide for Senior High School, Baesa, EC- TEC Commercial, 2016, 116.) Coal Formation Coalification is the formation of coal from plant material by the processes of diagenesis and metamorphism. Also known as bituminization or carbonification. It all starts with a swamp on the edge of a sedimentary basin, such as a lagoon or a lake. Tectonic activity raises sea levels, covering and killing vegetation. Plant debris accumulates and is buried under layers of mud and sand in a process known as sedimentation. This protects the debris from the air and slows down the decomposition process. The vegetation grows back, until the next flooding. The sedimentary basin gradually sinks under the weight of the sediments, and the layers of dead plants are subjected to rising temperatures that gradually “cook” them, leading to their transformation. The sedimentation undergoes the following stages: (1) turning cellulose—the main component of wood, from peat lignite (brown coal), (2) lignite to sub-bituminous coal, (3) to bituminous coal, and (4) finally to anthracite. Geological Time for The Formation of Coal The most favorable conditions for the formation of coal occurred 360 million to 290 million years ago, during the Carboniferous (“coal-bearing”) Period. However, lesser amounts continued to form in some parts of the Earth during all subsequent periods, the Permian (290 million to 250 million years ago), and throughout the Mesozoic Era (250 million to 65 million years ago). 3 The accumulated plant matter buried during the Tertiary Era less than 65 million years ago is generally less mature. It is often in the form of lignite, which still contains a high content of volatile matter (bitumen and decayed wood) and has a lower carbon content. However, there is also some higher rank coal from the Tertiary Era, coal that matured early, heated by plate tectonics. Examples of this include Paleocene coal (65 to 55 million years ago), found in Columbia and Venezuela, and Miocene coal (20 million years ago), found in Indonesia. In Indonesia, where the geothermal gradient is very high, anthracite lies close to the surface. However, the deposits in the Moscow Basin have never gone beyond the lignite stage as it is too cold. Finally, recent accumulations (from 10,000 years ago to today) are very rich in fibrous debris known as peat, in which the shapes of branches and roots can still be discerned. This material was not buried deep enough to contain elemental carbon. Types of Coal Description Brown, partially decayed plants fragments Peat Vegetation accumulates in wetlands (swamps, marshes, peat bogs, or lakes) Carbon content less than 60% Soft, dark brown, gray, or black, crumbly, sooty coal Formed from compaction of peat under low burial pressure and Lignite temperatures Carbon content 65-70% Sub-bituminous Intermediate between lignite and bituminous coal coal Carbon content 70-76% (dry basis) Hard, but slightly sooty Bituminous coal Dull to shiny luster Deep burial, longer burial, and higher temperatures than lower coal ranks Carbon content 70-86% (dry basis) Hard, shiny coal with silver luster A metamorphic rock formed from bituminous coal at higher Anthracite coal temperatures and pressures. The highest coal rank Carbon content 86-98% (dry basis) Different types of coal contain different amounts of carbon. The highest percentage of carbon is found in the highest rank of coal. The high-rank coal also has a higher heat content (or heating value). Petroleum (oil and gas) (Source: Catherine Abon, Earth Science Teaching Guide for Senior High School, Baesa, EC- TEC Commercial, 2016, 118.) 4 How Oil and Deposits are Formed The geological conditions that would eventually create petroleum formed millions of years ago, when plants, algae, and plankton drifted in oceans and shallow seas. These organisms sank to the seafloor at the end of their life cycle. Over time, they were buried and crushed under millions of tons of sediment and even more layers of plant debris. Eventually, ancient seas dried up and dry basins remained, called sedimentary basins. Deep under the basin floor, the organic material was compressed between Earth’s mantle, with very high temperatures, and millions of tons of rock and sediment above. Oxygen was almost completely absent in these conditions, and the organic matter began to transform into a waxy substance called kerogen. With more heat, time, and pressure, the kerogen underwent a process called catagenesis and transformed into hydrocarbons. Hydrocarbons are simply chemicals made up of hydrogen and carbon. Different combinations of heat and pressure can create different forms of hydrocarbons. Some other examples are coal, peat, and natural gas. Sedimentary basins, where ancient seabeds used to lie, are key sources of petroleum. In Africa, the Niger Delta sedimentary basin covers land in Nigeria, Cameroon, and Equatorial Guinea. More than 500 oil deposits have been discovered in the massive Niger Delta basin, and they comprise one of the most productive oil fields in Africa. Petroleum Reservoirs Petroleum is found in underground pockets called reservoirs. Deep beneath the Earth, pressure is extremely high. Petroleum slowly seeps out toward the surface, where there is lower pressure. It continues this movement from high to low pressure until it encounters a layer of rock that is impermeable. The petroleum then collects in reservoirs, which can be several hundred meters below the surface of the Earth. Petroleum can be contained by structural traps, which are formed when massive layers of rock are bent or faulted (broken) from the Earth’s shifting landmasses. Oil can also be contained by stratigraphic traps. Different strata or layers of rock can have different amounts of porosity. Crude oil migrates easily through a layer of sandstone, for instance, but would be trapped beneath a layer of shale. Geologists, chemists, and engineers look for geological structures that typically trap petroleum. They use a process called “seismic reflection” to locate underground rock structures that might have trapped crude oil. During the process, a small explosion is set off. Sound waves travel underground, bounce off the different types of rock, and return to the surface. Sensors on the ground interpret the returning sound waves to determine the underground geological layout and the possibility of a petroleum reservoir. The problem with burning fossil fuels is their effect on the environment. As mentioned, fossil fuels are Hydrocarbons. When hydrocarbons are burned in the presence of oxygen, they release carbon dioxide into the atmosphere. Carbon dioxide is a Greenhouse Gas and is a leading cause of Global Warming. (Source: “Petroleum”, National Geographic, last modified October 5, 2018, https://www.nationalgeographic.org/encyclopedia/petroleum/.) 5 Uses of Fossil Fuels Uses of coal: Coal is used in the generation of electricity. Also, used in electrical utilities, and products like dyes, aspirins, soap, fibers, plastics, and solvents have coal or coal by product. It is used in steel industry, pharmaceutical industry, cement manufacture, manufacturing of paper etc. Uses of oil: Crude oil or petroleum is also called as “black gold”. There are various uses of petroleum. It is used in the generation of electricity, used in transportation as fuel for automobiles and jets. The by-product of oil is used to produce chemicals, plastics, lubricants, tars, waxes, medicines etc. Also, many of the fertilizers, as well as pesticides, are made from either oil or its by product. Uses of natural gas: It is a gaseous fuel and primarily consists of methane. It is much cleaner than oil and coal. It is used in air conditioning, cooking appliance like fuel stoves and heat homes and buildings, heating water etc. It also provides electricity and is used in industries like steel foundries, glass foundries other manufacturing, aluminum smelters. It also produces paints, fertilizers, plastics, and dyes. NOT Let’s Practice Directions: Complete the concept map below by filling in the three (3) types of fossil fuels. Sources of energy are Non-renewable Renewable cannot be can be such as such as replenished wind biofuels Fossil fuels sunlight types geothermal Hydro power Direction: Give at least three (3) uses of fossil fuel. Write each of them on the boxes below. 6 Let’s Do More Directions: Cut the statements on the paper below into strips and organize them into the correct chronological order of how petroleum forms. Paste your answers on the next page. Please do not print at the back of this page. 7 Answers to “The Origin of Oil” Activity The correct order of statements is _________________. 8 Let’s Sum It Up Directions: Complete the following sentences. Write your answer on the lines provided. Coal, natural gas, and oil are all examples of ______________________ (renewable/non- renewable) energy resources. When they are burned, they release_________________ (energy/electricity). Coal, natural gas, and oil are also known as___________________ (nuclear fuels/fossil fuels). The _______________________ (sedimentation/coalification) is the process by which plant remains become coal. Directions: Analyze the statements below. Write FACT if the statement is correct and BLUFF if incorrect. Write your answer on the space provided before each number. ____________1. Fossil fuels are used to generate electricity. ____________2. The lignite coal contains 70-76% of carbon and 53% volatile matter. ____________3. The highest percentage of carbon is found in coal the lower the heating value. 14 ____________4. Petroleum is found in underground pockets called reservoirs. ____________5. A hot climate can contribute to the gradual growth of planktons. ____________6. Hydrocarbon traps may contain oil with significant quantities of dissolved gases. ____________7. The gas released from burning hydrocarbons can affect the environment. ____________8. An intermediate material kerogen can be converted or transformed into anthracite. ____________9. Gas dissolved in crude oil can be turned into liquified petroleum gas. ____________10. It is important to find fuels other than fossil fuels if humans want to use electricity in the future. Lesson 2 Geothermal and Hydraulic Energy Sources MELC: Explain how heat from inside the Earth (geothermal) and from flowing water (hydrothermal) is tapped as a source of energy for human use. (S11ES-le-11) Objectives: 1. Explain how geothermal and hydroelectric energy is tapped for human use 2. Distinguish geothermal and hydroelectric energy 9 Let’s Explore and Discover Geothermal energy stems from Earth's internal heat. Hot springs and geysers are produced by water that is heated by magma or hot rock below the surface. At a geothermal power plant, engineers drill wells into the hot rocks. Hot water or steam may come up through the wells. Alternatively, water may be put down into the well to be heated, it then comes up. The hot water or steam makes a turbine spin, this makes electricity. The picture below is an example of a geothermal power plant. (Source: US Government, http://commons.wikimedia.org/wiki/File:Geothermal_power_plant_in_the_United_States. JPEG.) Geothermal Energy as a Resource Because hot water or steam can be used directly to make a turbine spin, geothermal energy can be used without processing. Geothermal energy is clean and safe. It is renewable. There will always be hot rocks, and water can be pumped down into a well. Geothermal energy is an excellent resource in some parts of the world. In the United States, California leads all states in producing geothermal energy. The largest plant is in the Geysers Geothermal Resource Area. Geothermal energy is not economical everywhere. Many parts of the world do not have underground sources of heat that are close enough to the surface for building geothermal power plants. Hydroelectric power, or hydropower, harnesses the energy of water moving down a stream. Hydropower is the most widely used form of renewable energy in the world. This abundant energy source provides almost one-fifth of the world’s electricity. The energy of waves and tides can also be used to produce waterpower. Hydropower Plants To harness waterpower, a stream must be dammed. Narrow valleys are the best for dams. While sitting in the reservoir behind the dam, the water has potential energy. Water is allowed to flow downhill into a large turbine. While flowing downhill, the water has kinetic energy. Kinetic energy makes the turbine spin. The turbine is connected to a generator, which makes electricity. Benefits and Problems of Hydropower Waterpower does not burn fuel. So, it causes less pollution than many other kinds of energy. Waterpower is also a renewable resource. Water keeps flowing downhill. 10 (Source: National Aeronautics and Space Administration, http://commons.wikimedia.org/wiki/File:Lake_mead.jpg.) Waterpower does have problems. A large dam stops a stream's flow, which floods the land upstream (Figure above). A beautiful location may be lost. People may be displaced. The dams and turbines also change the downstream environment. Fish and other living things may not be able to survive. (Source: “Hydroelectric Power”, CK-12, last modified July 4, 2019, https://flexbooks.ck12.org/cbook/ck-12-middle-school-earth-science- flexbook2.0/section/unittest/Test-for-ESC-Unit55-5292199/.) Let’s Practice Directions: Please read all the questions carefully and make sure you understand the facts before you begin answering. Write your answer in the space provided. 1. How geothermal energy is harnessed? 2. What is the ultimate source of geothermal energy? 3. How is hydrothermal energy collected? Direction: Arrange the following events as to how the hydropower plants harnessed waterpower. Write the number in the box. The water to flows into a large turbine. As the water moves, it has kinetic energy, which makes the turbine spin. The turbine is connected to a generator, which makes electricity. In a hydrothermal plant, a dam across a riverbed holds a stream to create a reservoir. 11 Let’s Do More Directions: Use the table below to differentiate geothermal from the hydroelectric energy source. Write your answer in the space provided. Geothermal Hydroelectric A. Advantages B. Disadvantages Directions: Analyze the statements below. Write TRUE if the statement is correct and FALSE if incorrect. Write your answer in the space provided before the number. _________1. Geothermal energy is clean and does not release greenhouse gases. _________2. Hydroelectric power harnesses energy from dead plants and animals. _________3. The energy of waves can also be used to produce waterpower. _________4. Hot spring and geysers are produced by water that is heated by magma. _________5. The hot water or steam can directly produce electricity. Let’s Sum It Up Directions: Complete the following sentences. Write your answer on the lines provided. The ____________________ (hydroelectric/geothermal) energy is produced by heat of Earth’s molten interior. While ____________________ (geothermal/hydroelectric) power harnesses the energy of water moving down the stream. Both are considered _______________________ (renewable/non-renewable) energy sources because they _______ (can/cannot) be replenished or regenerated. 12 Let’s Assess Directions: Read the following questions. Choose and encircle the letter that correspond to the best answer. 1. How are fossil fuels formed? A. Dead organisms are buried B. Fossil fuels are renewable, so they are man-made C. Dead organisms fall to the bottom of the floor and pressure and cementation change it into fossil fuels D. Dead organisms fall to the bottom of the floor and are covered in sediment heat and pressure turn into fossil fuels 2. What is the relationship between sedimentary rock and fossil fuels? A. Fossil fuels are formed within the sedimentary rocks B. They are both renewable resources C. They are made from pressure and heat D. They both take millions of years to form 3. Coal often forms where once there were swamps. What characteristic of swamps is important to the formation of coal? A. Abundant (large amounts) plant life C. High temperature B. Frequent rains D. Reptile predators 4. Which of the following answers describe the correct order of the formation of fossil fuels? A. Coal, plants, and animal die, sediments are deposited, pressure, and heat. B. Fossil fuels are created through the process of photosynthesis. C. Humans create fossil fuels in a lab. D. Plants and animals die, layers of sediment, pressure, heat, time, then coal or oil or natural gas 5. What is the difference between the way natural gas and oil are formed to the way coal is formed? A. Natural gas and oil are formed by decomposed plant and animal matter; coal is formed by decomposed plant matter only. B. Natural gas and oil are formed by decomposed animal matter only; coal is formed by decomposed plant and animal matter. C. Natural gas and oil are formed by decomposed plant matter only; coal is formed by decomposed animal matter only. D. Natural gas and oil are formed by decomposed animal matter only; coal is formed by decomposed plant matter only. 6. Which among the following is true about geothermal energy? A. It is pollution-free C. It’s non-renewable B. It requires treatment before use D. None of the above 7. Which of the following is an example of a geothermal energy source? A. Geyser C. A only B. Hot springs D. Both A and B 13 8. How is hydroelectric energy harnessed for human consumption? I. The water can be used to turn the blades of a turbine to generate electricity II. The potential energy is converted into kinetic energy as water flows downhill III. Water gains potential energy just before it spills over the top of a dam or flows downhill A. I, II, and III B. II, I, and III C. III, II, and I D. III, I, and II 9. What type of resources are considered finite and cannot be replenished in a short amount of time? A. All energy sources C. Nonrenewable energy B. Generation energy D. Renewable energy 10. What type of fossil fuel is used to generate gasoline, jet fuel, kerosene and can also be used to generate electricity or to power vehicles? A. Coal B. Petroleum C. Oil D. Peat Answer Key Lesson 2-Let’s Practice Lesson 1 Activity 1 Let’s Practice (2, 3, 4, 1) Activity 1 Activity 2 1. Coal 1. Electricity 2. Petroleum 2. Fertilizer 3. Natural Gas 3. Plastics Let’s Do More Activity 1. The Origin of Oil: E, D, B, H, F, C, G, A, I, & J Activity 2 Let’s Sum Up Student’s answer may vary Activity 1 1. nonrenewable Let’s Do More 2. energy Activity 1. Activity 2 Let’s Sum Up 3. fossil fuels Geothermal Hydroelectric - geothermal -- hydroelectric energy is 1. T 3. T 1. geothermal 4. coalification energy is that it is inexpensive and also 2. F 4. T 2. hydroelectric Activity 2 clean reliable to harness 3. renewable Activity: Fact or Bluff - it does not - dams do not need to be 5. F 4. can require any fuel or complex, and the resources 1. FACT 2. BLUFF 3. BLUFF 4. FACT emit any harmful to build them are not 5. FACT 6. FACT 7. FACT 8. BLUFF pollutants into the difficult to obtain 9. FACT 10. FACT air. -- hydroelectric power - available in plants are damaging to the Let’s Assess certain parts of the environment. When a river world is dammed, it creates a 1. D 2. A 3. A 4. D 5. A 6. A 7. D large lake behind the dam. 8. C 9. C 10.C References 1. Book Catherine C. Abon, Earth Science. Teaching Guide for Senior High School. (Baesa, Quezon City: EC-TEC Commercial, 2016), 111-139 2. Website “Energy Sources”. Siyavula Education, Accessed 2015, https://intl.siyavula.com/read/science/grade-7/sources-of-energy/11-sources-of energy 14 FEEDBACK SLIP A. FOR THE LEARNER Thank you very much for using this CLAS. This learner’s material is aimed at ensuring your worthwhile learning through the help of your family members. For feedback YES NO purposes, kindly answer the following questions: 1. Are you happy and contented with your learning experiences using this CLAS? 2. Were you able to follow the processes and procedures that were indicated in the different learning activities? 3. Were you guided by anybody from your family while using this CLAS? 4. Was there any part of this CLAS that you found difficult? If yes, please specify what it was and why. B. FOR THE PARENTS / GUARDIANS Do you have any suggestions or recommendations on how we can make improvements to this CLAS to better serve the learners? Yes (Please indicate what this is/these are.) None Contact Number: __________________________________ NAME OF SCHOOL: Teacher’s Name and Signature: Parent’s / Guardian’s Name and Signature: Date Received: Date Returned: 15

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