Clintondale Virtual High School Application Form
Clintondale Virtual Schools · 20674 Hall Road · Clinton Township, MI 48038
586-465-9474 / 800-297-2119 Office · 586-465-9481 Fax

Print and complete this form according to guidelines in Admissions, then mail or fax it to the address above.

Name: _____________________________________________________________Date_____________
(Last)(First)(Maiden)

Address: ____________________________________________________________________________
(Street) (City) (State) (Zip)

Sex:___ M ___F Age:___ Birthdate: ______Phone: _____________/(Evening)____________

Social Security No._________________________ Last grade completed: 9 10 11 12 (Circle one)

Student e-mail address:______________________Parent e-mail address:________________________

Ethnic Origin (Required by Public Acts 88 & 89) __American Indian __Oriental __Hispanic __Caucasian __Other

Classes taken for:__credit recovery __enrichment __a diploma Parent day phone_________________

Last high school attended: _________________________________ Phone: _____________________

Address: ___________________________________________________________________________

Course Name / Course Number

1)______________________________________2)_________________________________________

Tuition fees are $325 per class. Number of classes ______ x $325 =________________

Credit recovery students only: Student's home school counselor: I certify the above information is correct
and our school will accept this student’s work from Clintondale Virtual High School for credit.

________________________________________ ________________________________________
(Counselor’s name printed) (Phone)

________________________________________ ________________________________________
(Counselor’s signature) (High School)

Policy Acceptance: I certify that I have read and agree with the four school policies in this site and that the above information is true.

________________________________________ ________________________________________
(Student signature) (Parent’s signature, if student is under 18)

Send payment payable to: Clintondale Virtual Schools or provide credit card information below:

Card Number: ______________________________________________ Exp. date: ________________

Name on card: _______________________________ Signature: _______________________________