JEDI Virtual School

Full-Time Student Enrollment Form

STUDENT INFORMATION

First Name
A value is required.

Middle Initial

Last Name

Date of Birth mm/dd/yyyy

Gender
Male Female

Address

City

State

Zip

Home Phone

Race Ethnicity White Black Asian Hispanic
Native American Other

Email

School Currently
Enrolled in
Resident School Home Schooled Private School
Drop Out Outside District

Does student receive special education services?
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

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			by checking this box you have created an electronic signature as legally binding as your handwritten signature