Private School Registration 2019 - 2020
All sections must be filled out.
Student's Full Legal Name *
Student's Preferred Name
Student's Date of Birth *
Student's email *
Put n/a if not applicable
Student Phone Number *
Put n/a if not applicable
Name of Primary Contact Parent/Guardian *
Relation to student *
Primary Contact email *
Primary Contact Preferred Phone Number *
Type of Phone
Primary Contact Alternative Phone Number
Alt. Type of Phone
Second Contact Parent/Guardian
Second Contact Relation to student
Second Contact email
Second Contact Preferred Phone Number
Second Contact Type of Phone
Second Contact Alternative Phone Number
Type of Phone - Alt.
Home Address(es) *
Emergency Medical Information
Emergency Contact if Parents are Unavailable *
List at least one person and their phone number
Person(s) Responsible for Billing *
Billing Contact's Phone Number *
Choose a Billing Option for Invoices *
**Quarterly invoices are sent out every three months and cover Sept - Nov, Dec - Feb, Mar - May, and June
Email Address for Invoices *
Grade for School Year 2019-20 *
List schools attended from 9th grade to present (including city and state). *
Diploma Granting Institution *
Courses Interested in Taking *
Teacher Preference(s)
List preferences if known.
Will Student Need Privett Van Transportation During the Day? *
If you answered yes to the previous question, please complete and return a transportation permission form found at the link below.
By submitting this form, you acknowledge that all information provided is accurate and agree to The Privett Academy's Fees & Policies.
The following is required before a student can be scheduled and services can be provided:
*A non-refundable registration fee of $500
*Course for Credit Registration Form
*Transportation Permission Slip (for students taking the van)
Never submit passwords through Google Forms.
This form was created inside of Privett Academy. Report Abuse