Full-Time High School Enrollment Application Jeffco's 21st Century Virtual Academy 2018/2019
Potential students and their parent(s)/guardian must complete the required enrollment steps before finalizing enrollment in Jeffco's Virtual Academy. (Please note enrollment into Jeffco's Virtual Academy is not automatic)

DO NOT USE THIS FORM FOR CREDIT RECOVERY

I understand that filling out this survey is the first step of the application process. I understand my student's enrollment is dependent upon successful completion of the Introduction to Jeffco's Virtual Academy and that all required paperwork has been submitted and reviewed by the registrar. *
Required
I acknowledge that this application is for high school regular courses. I understand a response will not be generated if this application is for any course/grade level other than what is stated in the application title. *
If you need middle school or credit recovery courses, please return to our website for the appropriate application.
Required
What is your Jeffco Student ID Number *
Your answer
Student Last Name *
Please provide student's legal last name
Your answer
Student First Name *
Please provide legal first name
Your answer
Student Middle Name *
Please provide full middle name
Your answer
Name of Current School *
Your answer
Student Grade Level for the 2018/2019 School Year *
Required
Student Date of Birth *
Day, Month and Year (xx-xx-xxxx)
Your answer
Name and email address for Student's Current Counselor *
Your answer
Student Email Address *
Your answer
Student Phone Number
Your answer
Parent/Guardian Name *
Please provide the following information for student's parent/guardian
Your answer
Parent Phone Number *
Your answer
Parent Email Address *
Your answer
Please Enter Parent Email Address Again *
Your answer
Home Address *
Your answer
City/Town *
Your answer
State *
Your answer
Zip Code *
Your answer
Relationship to Student *
Your answer
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