Independent Study Program Enrollment Form Student Information Student Name:   Gender: female  male Grade:   Yes No Somewhat   Yes No Somewhat Enjoys Reading? Have outside interests? Favorite Book? Learning disability? Struggle with math? Is talented? Participate in sports? Easily discouraged? Socializes with peers? Good organization? Enjoy hobbies? Exhibits confidence? Notes (include specific information on above)   Areas of Student Need   Main reason for seeking independent study approach to learning:   Indicate program student attended during the last 12 months:   Curriculum preference:  Text Based   Online   Project Based   Custom  Transcript provided/requested: yes no Learning Style Profile Administered: yes no Expectations, Learning Style Profile, & Fees reviewed: yes no Contact Information: Parent or Guardian Name: Street Address: Mailing/Shipping Address (if different): Apt #: Apt #: City: City: State: State: Zip: Zip: Daytime Phone: Evening Phone: Cell: Date of Birth: Student Email: Parent Email: Date Enrolled: iChat User Name: Get one here
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