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Genesis Enrollment Form
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Student Information
Student First Name
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Your answer
Student Last Name
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Your answer
Male/Female
Male
Female
Student Email Address
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Your answer
Student Cell Phone Number
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Your answer
Grade Level
Your answer
Current School Name
Your answer
Course Information
Course Start Date
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Your answer
Course End Date
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Your answer
Course Term
Choose
Semester Course 1/2 year
Year Long Course
Desired Course or Courses
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Your answer
Reason For Enrollment
Advanced Coursework
Credit Recovery
Special Interest Course
Not Offered at School
Scheduling Conflict
Other:
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
Your answer
School Liaison Phone Number
Your answer
School Name
Your answer
School Address, City, Zip Code
Your answer
Student Date of Birth
Your answer
Person submitting this form
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Parent
School Liaison
Principal
Student
Other
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