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 studentís home high school: I certify that the above information is complete and correct and that our school will accept this studentís work from Westley-Davis Academy for credit. 

___________________________________   ______________________________________
(Counselorís name printed)                                                   (Phone)
___________________________________   ______________________________________
(Counselorís 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) 

____________________________________   _____________________________________
(Parentís 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

214-295-9434 Fax