USD 258 Humboldt - Enrollment Application

Must be a Kansas Resident to enroll.

Enrollment Applications are evaluated before your enrollment interview is scheduled. We work hard to determine if our program is the appropriate educational placement for each student to be successful. Acceptance into our program will be determined by the Humboldt Virtual Program Director. Requirements are aligned with USD 258 Humboldt Virtual Programs policies.

PLEASE watch the enrollment video before filling out the enrollment application.

9th-12th Grade Enrollment Video https://www.youtube.com/watch?v=7Gzd7gMnm_A

Adult Enrollment Video (20 Years Old and Older) https://www.youtube.com/watchv=KX9cv40XY-8

Progress Portal Video for Parents, Guardians, Probation Officers, etc. https://www.youtube.com/watch?v=m3_qaEkRapo

Humboldt Virtual Education Program Enrollment Form

Last Name

First Name

Middle Initial

Maiden Name

Enrollment Type

Student Phone #

Student Email or Facebook

Address

City

State

Zip Code

Who referred you to us?

Date of Birth MM/DD/YYYY

Gender

Age

Ethnicity

Hispanic or Latino

Employed

Post-Secondary Choice

Career Choices

Have you earned a high school diploma?

Last Grade Completed?

Graduation Year

Former High School

City

State

School Phone #

School FAX #

I give consent to the Virtual staff to discuss my progress or attendance with the person(s) listed above. Initials in box.

I give Humboldt Virtual permission to request, transfer or discuss my school records with other high schools or post-secondary choices.

Why did or do you want to leave your local school?

21 and Under

Do you currently have an IEP?

Services provided in your IEP

Resource Room Time

Extra Time on Tests

Reading

Math

Behavior

Release of Information-Next TWO Sections

We cannot release your personal information without your (or parent if under 18) consent in accordance with the Family Educational Rights and Privacy Act (FERPA) Please list the name(s) of person(s) who may receive information regarding your progress or attendance.

Please list TWO additional contacts- Family, Friends, Guardian, ect

1st Contact Name

Phone #

Relationship to you

2nd Contact Name

Phone #

Relationship to you

Do you have a Probation Officer?

Name

Phone #

Town

Do you have a Caseworker?

Name

Phone #

Town

Do you have a computer?

Do you have internet?

Do you want your name, address and phone number given to any military recruiters or post-secondary schools?

All students 18 & under, on September 20th, require district approval.

HS Student - Full Name

Initial Max: 2

Parent - Full Name

Initial Max: 2

Adult Student - Full Name

Initial Max: 2

Email a copy to

optional

Required Fields