Part-Time Online High School Registration

Student Name*

First Middle Last

Student Email*

Date of Birth*

Format: mm/dd/yyyy

Country of Birth*

Home Address*

Street Address Address Line 2 City State ZIP Code

Grade Level*

Home Phone*

Gender*

Race/Ethnicity*

Primary Language*

Parent/Guardian Name*

Parent/Guardian Email*

Parent/Guardian Work Phone*

Student is Special Needs with IEP*

Student is Special Needs with 504*

Student is Part-Time

Select Subject #1*

Select Class #1*

Select Subject #2

Select Class #2

Current High School*

Previous High School*

Comments

I verify the above information is correct*

Part-Time Registration