Pathways Academy Student Enrollment Form

Student Enrollment Form
Thank you for your interest in eCampus Academy. The purpose of this form is to assist eCampus staff with planning and preparing to provide the best possible support for students and parents.

Student Information
Name

First NameLast Name
Gender:

MaleFemale
Student Email Address:*
example@example.com
Date of Birth:*

MonthDayYear
Date
Language(s) Spoken at Home:*
Ethnicity:*
Race:*
Does the Student Speak English?

YesNo

ENROLLMENT INFORMATION
Current Grade (2022-23 School Year)
Desired Start Date:

MonthDayYear
Date
Please upload a current transcript if available.

Cancelof
Additional Services Requested:

TutoringAP CoursesOther
Is there a local learning coach that will be working with this student?

YesNo
Learning Coach Name:

First NameLast Name
Learning Coach Title:*
Learning Coach Email Address:*
example@example.com

FAMILY CONTACT INFORMATION
Name:

First NameLast Name
Relationship to Student:*
Home Address:
Phone:
Email:*
example@example.com
Preferred Way to be Contacted:

EmailPhoneNo Preference
Should be Empty: