JEDI Virtual High School

Single Course Registration Form

STUDENT DEMOGRAPHICS

First Name

Middle Initial

Last Name

Date of Birth mm/dd/yyyy

Gender
Male

Female

Student Address

City

State

Zip

E-mail Address

Home Phone

Cell Phone

Graduating Class Of

Parent Contact Information

Parent Name

Relationship to Student E-Mail Address

Phone

Address

City

State

Zip

RESIDENT DISTRICT

Name of School District (resident)

City /State

Zip

Assigned On-Site Monitor

Monitor E-Mail Address

District Contact Person

Contact E-Mail Address

Phone

If your student needs an attendance waiver to meet the DPI mandetory attendance laws, please contact JEDI Virtual School Student Services to schedule an enrollment meeting for your student.

PLEASE CHOOSE THE OPTION THAT BEST FITS YOUR STUDENT.

Student needs an attendance waiver to be in compliance with mandetory attendance law.

Student is attending in district building to meet mandetory Attendance Requirements

Other- Please explain below.

COURSE REQUEST INFORMATION

I request the following course(s) to be taken during the upcoming school year. Unless you request an EARLIER end date in the NOTES section, the student will be given 5 months (or to the end of the 1st week in June for 2nd semester enrollments) to finish the course.

Course #1	Note 1:
Course #2	Note 2:
Course #3	Note 3:
Course #4	Note 4:
Course #5	Note 5:
Course #6	Note 6:
Course #7	Note 7:

APPROVAL

School Official	Date mm/dd/yyyy	School Code
by checking this box you have created an electronic signature as legally binding as your handwritten signature. **