Jackson County Virtual Program Application 2019-2020
Please complete the following application for the Jackson County Virtual Program. All fields must be completed in order to be considered for this program. An application must be submitted for each student. Please contact Chris Davis, Director of Special Programs for additional information. Contact information: davisc@jacksonk12.org or 256-259-9507.
Email address *
Student's First Name *
Your answer
Student's Middle Name *
Your answer
Student's Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Physical Address *
Your answer
Is this the Guardian's address? *
Parent/Guardian's First Name *
Your answer
Parent/Guardian's Last Name *
Your answer
Phone Number #1 *
Your answer
Phone Number #2 *
Your answer
Email Address *
Your answer
Currently enrolled in what school? *
Your answer
City & State *
Your answer
Grade Level for the 2019-2020 School Year *
Have you been identified with Dyslexia? *
Are you served under a 504 plan? *
Are you served under an IEP? *
Have you had a Truancy referral or warning? *
Do you have a copy of your transcripts? *
Do you have a pending discipline issue or due process hearing? *
Do you have high-speed internet at your home? *
What kind of devices do you have at home? Check all that apply. *
Required
Is transportation available, by a guardian, for the student to attend meetings at a Jackson County campus weekly and as required? *
Reasons for wanting to enroll in the Virtual School Program: *
Your answer
Submit
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