Global E-Learning Registration Form

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Student Name: *

Current Grade Level *

Student Type *

Student Birthdate *

YYYY

Parent Name *

Parent Telephone Number *

Parent Email *

Mailing Address *

Mailing Address is the same as physical address *

Yes

If No, what is the physical address:

Will an adult be available to devote 25 hours per week to serve as a learning coach or can the student work independently? *

yes

Does the student have an IEP or 504 Plan? *

Yes

Do you have high speed internet? *

Yes

Middle and High School Only: Are you interested in playing a sport or participating in band on campus?

Sport

Band

Chorus

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