Genesis Enrollment Form
Student Information
Student First Name *
Your answer
Student Last Name *
Your answer
Student Email Address *
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Student Cell Phone Number *
Your answer
Grade Level
Your answer
Current School Name
Your answer
Course Information
Course Start Date *
Your answer
Course End Date *
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Course Term
Desired Course or Courses *
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Reason For Enrollment
Parent Information
Parent First Name
Your answer
Parent Last Name
Your answer
Parent Email Address
Your answer
Parent Phone Number
Your answer
School Information (if applicable)
Please complete this section if the student's school is enrolling the student or has recommended the student to take a Course at Genesis.
School Liaison First Name
Your answer
School Liaison Last Name
Your answer
School Liaison Position
Your answer
School Liaison Email Address
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School Liaison Phone Number
Your answer
School Name
Your answer
School Address, City, Zip Code
Your answer
Other Information
Your answer
Person submitting this form *
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This form was created inside of Genesis Virtual Academy.