Enrollment Form

Welcome to Upper Penninsula Virtual Academy Online Enrollment Form.

Items in bold are required.



Enrollment Date:
Student’s Full Name:  
Grade:  
Home Address:  
City:  
Zip:  
Gender:
County Residence:  
Township of Residence:  
Birth Date:  
Age:  
Birth City:  
Birth State:  
Name of Parent(s)/Legal Guardian(s):
 
Relationship:  
Phone:  
Cell:
Name of Parent(s)/Legal Guardian(s):
Relationship:
Phone:
Cell:
Parent/Guardian Email:  
Student Email:
Cell Phone:
Last School Attended:
Phone Number of School:
School Address:
City:
State:
Zip:
Why are you seeking a seat time waiver option? Check all that apply. (Appropriate documentation may be required.)
  Traditional Learner
  Accelerated Learning
  Pregnant
  Expelled
  Long Term Suspension
  Working Student
  Home School Non-Essential Course Student
  Social Emotional Family Issues
  Medical Situation
  High Interest/Low Enrollment Courses
  Other
Please specify  
Do you have an IEP or 504 plan?

If Yes, please give a brief description of the IEP or Section 504 plan.  


Student Signature:  
Parent/Guardian Signature:
 
Date:
Word Verification: Type the characters you see in the image below:

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Thank you for your interest in the Upper Penninsula Virtual Academy. Once you have submitted the form, a UPVA school official will contact you to complete the enrollment process.