Coffee County Virtual Academy Student Application for Semester 1
Thank you for your interest in the Coffee County Virtual Academy -- Please complete the following application for consideration.

Please check the student handbook at the CCVA website: https://ccva.k12coffee.net/ for details.
Sign in to Google to save your progress. Learn more
Email *
Student's Grade Level for 2022/2023 School Year? *
Must be a numerical value
Student's First Name *
Student's Last Name *
Current School *
Mark all that apply *
Required
Student's Gender *
Student's Birthday *
Was the student a distance learner during the 2021/2022 year? *
Home Physical Address *
Parent/Guardian #1 Name *
Parent/Guardian #1 Phone Number *
Parent/Guardian #1 Email Address *
Parent/Guardian #2 Name *
Parent/Guardian #2 Phone Number *
Parent/Guardian #2 Email Address *
Does the student have an IEP for SPED or Gifted Services or a 504? *
Does the student take ESL (English as a second language) classes? *
Does the student have reliable internet access at home? *
Does the student (and parent) agree to use a CCSS issued chromebook? *
Do you agree to have the student attend state required testing at the site location? (This is typically spread over three to four days and occurs during school hours.) *
Will you be able to attend our on-site student orientation? (should occur during the first two weeks of the school calendar) *
Who will be the student's caregiver that checks daily progress? *
Do you agree to an in-person or phone interview? *
Enter Today's Date *
MM
/
DD
/
YYYY
Please explain why you are a prime candidate for the Virtual Academy. *
By typing your name in the box below, you certify that the above information in this application is correct. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of K12coffee.net. Report Abuse