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.

Humboldt Virtual Education Program Enrollment Form

Last Name

First Name

Middle Initial

Maiden Name

Enrollment Type

Cell 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

21 and Under

Do you currently have an IEP?

Services provided in your IEP

Resource Room Time

Extra Time on Tests

Reading

Math

Behavior

Former High School

City

State

School Phone #

School FAX #

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

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

Contact Name

Phone #

Relationship to you

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?

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

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

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