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Yorktown Virtual Academy Application
Please fill out this information to apply for Yorktown Virtual Academy.
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Email *
Student Information
Student Last Name *
Student First Name *
Student Middle Name
Student Email address (if applicable)
Student phone number (if applicable)
INCOMING grade level (2023-2024 school year): *
Current School/Last School Enrolled In: *
Student was enrolled in 2022-2023 in which of the following settings: *
Date of Birth *
Primary Physical Address *
City *
State *
5-Digit Zip Code *
Parent/Guardian Information #1
First Name *
Last Name *
Relationship to Student *
Work Phone *
Home/Mobile *
Parent/Guardian Email *
 Second Parent Guardian #2- or Learning Coach designee
Learning Coach designee will be working with student in virtual learning setting
First Name *
Last Name *
Primary Physical Address (if different from student)
Zip Code
Home/Mobile of Parent/Guardian #2 or Learning Coach *
Parent/Guardian #2 Email or Learning Coach *
Is the student currently in good academic standing? *
Please tell us why this student would like to be enrolled in Yorktown Virtual Academy. *
Is this student self-motivated? (1=not at all to 10=highly motivated) *
Not at all
Highly motivated
Are you, as the parent/guardian and/or learning coach designee, willing to provide the necessary supports for your child to be successful in an online learning program? *
Does this student have access to the Internet? *
The information submitted on this form is true and accurate as of the date of this form. I understand that all information contained in this application will be verified by Yorktown Virtual Academy. *
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