9th-12th Grade Independent Study Program Registration Form (one per family)

School Year: *

Total number of 9th-12th students registering in your family: *

Student 1 Full Name (First, Middle, Last): *

Student 1 Date of Birth (MM/DD/YY): *

Student 1 Grade Level: *

Student 2 Full Name (First, Middle, Last):

Student 2 Date of Birth (MM/DD/YY):

Student 2 Grade Level:

Student 3 Full Name (First, Middle, Last)

Student 3 Date of Birth (MM/DD/YY):

Student 3 Grade Level:

School County Zoned For (reporting): *

If new to FBA Umbrella, where should records be requested from (include email address)?

Primary Teaching Parent Name: *

Primary Contact Number: *

Does Primary Teaching Parent work outside the home? *

Yes No

Father’s Name: *

Father’s Occupation: *

Mother’s Name: *

Mother’s Occupation: *

Are parents married to each other? *

Mailing Address: *

Address 1
Address 2

City

State

Zip

Is there any other person who is legally responsible for academic decisions? *

Yes No

If yes, please attach legal documentation here:

(allowed file types: jpg, pdf, png)

Is there any other person who will be responsible for teaching your child? *

Yes No

If yes, please describe the arrangement:

Church you attend faithfully/regularly: *

Emergency Contact Name (other than above): *

Emergency Contact Number (other than above):

Any medical diagnoses that may require testing accommodations?

Any special education needs that may require testing accommodations?

Has student ever had an IEP or 504 in public school? *

Yes No

Is student currently performing at grade level in all subjects? *

Yes No

If not, please provide details.

Will your 9-10th grader(s) be participating in the Pre-ACT test in April?

Yes No

Will your 11-12th grader(s) be participating in the ACT test in April?

Yes No

Will you need any special testing accommodations for either of those tests (will follow-up on this)?

I have truthfully completed the registration information to the best of my knowledge. *

Yes No

I agree with the FBA Statement of Faith (located under the Homeschool Registration Tab). *

Yes No

I understand that at least 180 days of school must be attended, with a minimum of 4 hours a day. *

Yes No

I am paying FULL tuition up front. *

Yes No

Enter Your Email Address: *