Date of Application			
	
Student Information	
Name					
	First	Middle	Last	Date of Birth	
Address				
	Number	Street	Apt. #	
					
	City	State	Zip Code	Phone	
Email		
	
Current School	
School			
	Name of School	Phone	
	q Cyber Charter School / E-School	q Home School	q Traditional School	
Contact				
	First	Middle	Last	
Address				
	Number	Street	Apt. #	
				
	City	State	Zip Code	
Reason for attending
the [Farrell Area Virtual Academy]		
Potential scheduling conflicts		
	
Parent(s)/Guardian(s) Information	
Name				
	First	Middle	Last	
Address				
	Number	Street	Apt. #	
					
	City	State	Zip Code	Phone Number	
Email		
Signature	X	
Name				
	First	Middle	Last	
Address				
	Number	Street	Apt. #	
					
	City	State	Zip Code	Phone Number	
Email		
Signature	X	
	
United States Department of Education Ethnic Codes:	
q Native American	q Asian/Pacific	q African American	q Hispanic	q Caucasian	
Grade Level:			Special Ed:	q Yes	q No		ESL:	q Yes	q No	
	
For Office Use Only:	
Student School ID Number:		Date of Received Application:		
Date of Interview:		Orientation Date:		
Family/District Agreement Date:		Enrollment Date:		

Is the Farrell Area Virtual Academy the right fit for me?

To find out if you have what it takes to be a successful Farrell Area Virtual Academy student, place a number next to each statement that best describes you as a student:

4 =	Strongly Agree
3 =	Agree
2 =	Disagree
1 =	Strongly Disagree

I CAN USE THE COMPUTER AS A TOOL FOR LEARNING…	
	I can communicate using email	
	I can use Microsoft Word as a writing tool	
	I can search for and locate information on the Internet	
	I can participate in on-line chat rooms	
	
I POSSESS THE SKILLS NECESSARY TO BE A SUCCESSFUL CYBER STUDENT…	
	I can follow and respond to written directions easily	
	I can use my time efficiently and submit my assignments on schedule	
	I am self-motivated, self-directed, and self-disciplined in regards to my studies	
	I can work independently	
	
I AM READY TO MAKE A COMMITMENT TO CYBER EDUCATION…	
	I am willing to spend 5.5 hours per weekday at my computer	
	I am willing to spend an additional 1-2 hours per week completing additional assignments	
	I am honest and can be trusted to do my own course work and assignments	
	I am responsible and will care properly for school-issued equipment	
	I am aware that my success as a Cyber student is my responsibility	
	I am willing to contact VLN Tech Support, when needed	

Please complete the following:

I have high-speed internet access in my home:	q Yes 	q No 	
The last academic grade I have completed:		

X		
Student Signature	Date	
		
X		
Parent/Guardian Signature	Date	

Why do you want to enroll in
the Farrell Area Virtual Academy?

Please compose a two to three paragraph essay that outlines the reasons why you would like to attend the Farrell Area Virtual Academy:

X		
Student Signature	Date	

Upon enrolling in the Farrell Area Virtual Academy, I agree to: 
•	Complete the Farrell Area Virtual Academy enrollment process
•	Provide my transcript from the 2016-17 school year at time of application
•	Notify the Farrell Area Virtual Academy Cyber Coordinator of any difficulties connecting to the curriculum delivery system
•	Notify the Farrell Area Virtual Academy Cyber Coordinator for support, as needed
•	Notify the Farrell Area Virtual Academy Cyber Coordinator of any change in status
•	Document evidence of active participation in all courses in which I am enrolled 
•	Complete all courses in which I am enrolled in their entirety within the specified time allotted
•	Complete all mandated medical screenings prior to enrolling in the program
•	Complete all required statewide testing at specified FASD building
•	Be removed from Farrell Area Virtual Academy if found to be involved in any form of academic impropriety 
•	Acknowledge that failure to complete enrolled courses may result in truancy charges and that student/parent/guardian may be responsible for paying related costs in full
•	Return equipment within one week of completion of, or withdrawal from, Farrell Area Virtual Academy program. Failure to do so may result in additional charges
•	Return all textbooks to the FASD within one week of completion of, or withdrawal from, Farrell Area Virtual Academy program, if applicable. Failure to do so may result in additional charges  
X		
Student Signature	Date	
		
X		
Parent/Guardian Signature	Date	
		
X		
[Farrell Area Virtual Academy] Cyber Coordinator Signature	Date