Westley-Davis Academy Online
3306 W.
Walnut, Suite 410
Garland, Texas
75042
214-703-8483 Main
214-295-9434 Fax
Complete this form according to
guidelines listed in "Admission"
Name:
______________________________________ Date
________________________
(Last) (First) (Maiden)
Address:
_________________________________________________________________
(Street) (City) (State) (Zip)
Sex:___ M ___F Age:___ Birthdate:
____/____/___Phone: __________/___________
(Emergency)
Social Security #________________
Mother's Maiden Name: _____________________
(Required)
Most
valid e-mail address:
_________________________________________________
Ethnic
Origin (Required
by Public Acts 88 & 89) __American
Indian __Oriental __Hispanic
__Caucasian
___Other
U.S. Citizen: _Y _N Country of Birth:
____________ Last grade completed: 9 10 11 12
(Circle one)
I am taking Westley-Davis Academy classes
for:__credit recovery
__enrichment
__a diploma
Last high school attended: __________________________
Phone: _________________
Address:
__________________________________________________________________
Sign here to give us permission to request a transcript: _______________________
Course
Registration:
Only
students who do not need a Westley-Davis
Academy Online counselor should complete this information:
| Course Name/Course Number | |
| 1) | 2) |
| Tuition fees are $_______ per class. Number of classes ______ X $______=_______ | |
Registration
Fee: $_____ application processing fee
(If accepted, this fee will apply to your tuition). Submit only if you are not
registering for classes and submitting tuition.
Attach proof of
age: Submit a copy of one of the
following - birth certificate or shot record or previous educational records or
copy of drivers license, or state identification.
Credit recovery students
only: Counselor from student’s home high
school: I certify that the above information is complete and correct and that
our school will accept this student’s work from Westley-Davis Academy for
credit.
___________________________________
______________________________________
(Counselor’s name
printed)
(Phone)
___________________________________
______________________________________
(Counselor’s
signature)
(High School)
Policy Acceptance: I certify that I have read and agree with
all the school policies.
________________________________________ (Student
signature)
I certify that the above information is as true and accurate
as possible.
_________________________________________ (Student signature)
____________________________________
_____________________________________
(Parent’s signature, if student is under 18)
(Please print name)
Parent day phone: _____________________ Parent e-mail:
________________________
Enclose a check or money order payable to: Westley-Davis Academy Online
Type of card: ___________________________
Card Number: ___________________________________ Exp. date:
_________________
Name on card: _______________________ Signature:
____________________________
Office use only Tuition ________________ Payment received by ___________________
| Office Use Only: | |
| Tuition | Payment Received By: |
Please
mail or fax application to:
Westley-Davis Academy Online
3306 W. Walnut, Suite
410
Garland, Texas 75042