Student Information:                                               * Required Fields

Student’s Full Name *

Birthdate *  mo/day/yr       Male Female

Last Grade Completed *    Current Grade * 

Previous School Information:

Last School Attended *

School Address *

City *   State *   ZIP Code * 

Last Date Attended mo/day/yr    Currently Enrolled * Yes No

Parent Information:

Father (or Guardian) * 

Mother (or Guardian) * 

Shipping Address *Not a Post Office Box

City *    State *  ZIP Code *

Mailing Address *

City *    State *  ZIP Code *

Home Telephone * Cell Phone

Work Telephone Ext.   Mother's  Father's

Email Address *

If a person other than the parent or guardian will be supervising the student,
please enter the name and relation of that person


Course Requested:

Curriculum Preference:
Please indicate if you prefer computer-based curriculum or workbook-style curriculum. There are advantages to both. You may even combine the two. In any case, you may want to call and discuss the advantages of either with one of our Education Specialists. Remember, there is an extra cost for the computer-based curriculum. The extra cost is an additional $15 per course per year.
Workbook-style
Computer-based
Combination of Workbook-style and Computer-based

Registration Fee:
.Registration Fee:......................... *
3rd - 8th grade: $25.00 or
9th - 12th: $35.00

Tuition Fee:
Tuition Fee: ...................................

Total Fees:
Total Fees (Add Registration & Tuition) ..... *

Payment Details:
You may confidently e-mail this Application with your credit card information.

Type of card:            VISA            MASTERCARD

Account # *

Expiration date  *    Security code *

Name on Account *

Billing Address *

City *     State *   ZIP Code *

                                   

  * Required Fields