JEDI Virtual School

Student Enrollment Form

Complete and submit this form for students enrolling in the JEDI Virtual School.

 
 
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STUDENT INFORMATION
First Name
  		Middle Initial
 Last Name
  		Date of Birth mm/dd/yyyy ------- AGE
  -----------

Gender
Male Female
Address
  		City
  		State
  		Zip
 
Home Phone
  		Race Ethnicity White Black Asian Hispanic
Native American Other 		E-mail
School Currently
Enrolled in

Resident School Home Schooled  Private School
Drop Out Outside District

Does student receive special education services?
Yes No

Parent,Guidance, or IEP team has determined virtual school to be an appropriate placement.

Yes No
Primary Language
 Does student have any specific health concerns?
(Please List) 		Has student been recommended for expulsion?
No Yes (explain)
PARENT INFORMATION
First Name
  		Last Name
  		Preferred Phone
  		Alternate Phone
 Alternate Phone
Address
  		City
  		State
 Zip
Parent E-Mail
 Occupation
 		 Best Time to Call

ACCESS INFORMATION
Anticipated Learning Site
 School Library Home Other 		Will student have access to computer with Windows 2000 or better? Yes No Access to High-speed Internet?
Yes No
RESIDENT SCHOOL INFORMATION
Name of School District (resident)
 Principal's Name
 School Phone
School Address
 City
 State
 Zip
Guidance Counselor's Name
 		 Are appropriate immunization records on file in resident district?
 Yes No All except
ACADEMIC PROGRESS INFORMATION
Student Grade Level


Class Of

Credits Earned

GPA
 

AGREEMENT
I understand that to enroll in JEDI Virtual High School I must withdraw from the school I am currently enrolled in and enroll in the JEDI Virtual School using this form.  I understand that I will be given a learning coach who will provide daily guidance, and that I will comply with the learning schedule put forth by the on-line course instructors.  Students who successfully complete the  graduation credit requirements can receive a JEDI Virtual HIGH School Diploma.  JEDI coursework also applies toward the requirements to receive a diploma from the student resident school.
Student Signature
 Date mm/dd/yyyy
 Parent Signature
 Date
mm/dd/yyyy
by checking this box you have created an electronic signature as legally binding as your handwritten signature  

For Office Use:

Student will be registered in the following courses upon enrollment.

Course #1

  Note:  

Course #2

  Note:  

Course #3

  Note:  

Course #4

  Note:  

Course #5

  Note:  

Course #6

  Note:  



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