Online Enrollment Form

INTERNATIONAL VIRTUAL
LEARNING ACADEMY

ONLINE ENROLLMENT FORM

Your Name:	Your Email:

Student Name
Date of Birth	Entering Grade
Parent / Guardian
Street
P.O. Box
City	State Zip
Email Address
Home Phone	Alt Phone
Current School

	*Payment is required with enrollment
	$150.00 Summer School $250.00 Full Year
*Credit Card:	Card Number
Expiration Date
Card Holder Name
Street:
City:	State: Zip:

Courses Requested
Assistance Needed:	Please indicate (special services, extra assistance in math, reading, etc.)
Considerations:	Please include any information which the IVLA staff should be apprised.
Documents:	Please list any forms or documents provided for review by IVLA.
	I have read, understand and agree to the Enrollment Agreement

I understand upon completion of this form I am pre-enrolling my student in International Virtual Learning Academy and will be required to pay the registration fee. After submitting this form a school administrator will contact me to verify course placement and provide login information. To request more information - CLICK HERE