Student Application

Please enable JavaScript in your browser to complete this form.

Date MM/DD/YYYY

Student's Name

First

Middle

Last

Main Contact Email

Confirm Email

Student's Date of Birth (MM/DD/YYYY)

Sex

Intended Year of Entry

Student Grade Level for Fall 2024

Program Desired

Are you applying for a scholarship with this application?

Child's Home Address (Please provide complete address.)

Please include house number, street name, city, state, and 5 digit zip code. This application must contain a current mailing address for your child. We may ship books, curriculum, documents, and other items directly to your home.

Mother's Full Name

Mother's Phone Number (000-000-0000)

Please provide your most accessible contact number.

Mother's Full Address

If same as child’s address, write SAME.

Mother's Email

Mother's Occupation and Employer

Father's Full Name

Father's Full Address

If same as child’s address, write SAME.

Father's Email

Father's Occupation and Employer

Student's Parents Are…

EMERGENCY CONTACT PERSON (Someone not living with you)

First

Last

Emergency Contact's Address (address, city, state, zip, country)

Emergency Contact's Relationship to the Child

Emergency Contact's Phone Number

Please explain any special family circumstances that may affect your child’s learning:

Is student supervised by the courts in a joint custody case?

Is any person(s) expressly prohibited from having contact with the child?

Has the student ever been expelled from any public or private school?

Does the student have any past criminal record?

If you answered YES to any of these questions, please explain below. All information will be kept confidential.

PARENT PERMISSION CONFIRMATION

By selecting “YES”, I acknowledge that either parent or guardian above may obtain information for my student from Experius Academy at any time. Any exceptions must be specifically described in writing, and sent by mail to Experius Academy; PO Box 158; Manti, UT 84642.

STUDENT HEALTH

Does student have any health condition, physical or emotional, that may require special accommodations in his/her education? If yes, explain.

LEARNING ACCOMMODATION

Does student have, or has he/she ever had an IEP, a 504, or any other type of customized learning plan or accommodation? If yes, please explain.

FINANCIAL RESPONSIBILITY

First

Last

Person responsible for tuition and fees and relationship to the student, if any.

Billing Address

Address, City, State or Province, Zip or Postal Code, Country

ACADEMIC HISTORY

List all schools student has attended, beginning with the most recent. We will use this address to request your student’s records. Please include school name, complete address, school phone number, and name of school counselor, if available.

INTERESTS AND HOBBIES

Please list activities, sports, musical instruments, hobbies, community service, etc. in which the student has participated during the last three years.

ACADEMIC INTERESTS AND STRENGTHS

Which classes/subjects do you most enjoy and why? Which classes/subjects do you least enjoy and why? What do you feel are your personal strengths? Why do you want to attend Experius Academy?

PERSONAL ESSAY (ages 12 and older)

Tell us about a person or event that has had a great affect on your life; or tell us your thoughts about what your mission in life might be.

STATEMENT of AGREEMENT & UNDERSTANDING

I understand that my child will be required to abide by the code of conduct. Violation of this code will be grounds for dismissal. I also understand that no fees will be refunded if my child is refused participation in school activities due to misconduct.

PERMISSIONS

The information herein given is for the purpose of obtaining admission to Experius Academy. I certify that it is correct to the best of my knowledge. I give Experius Academy administrative personnel my permission to contact former schools and/or references for the purpose of determining admission to the Academy.

APPLICATION FEE

I understand that an application/testing fee of $100.00 must accompany this application. If I withdraw my application, I understand the fee is not refundable.

INTERNET CONNECTION

The Academy’s online program necessitates a reliable internet connection to deliver content and submit assignments. Please acknowledge that you have a good internet connection available on a daily basis.

PARENT SIGNATURE

By typing my name, I am confirming that the information I have provided is true and complete to the best of my ability. If any information changes, I will contact the school.

Did someone refer you to Experius Academy?

If someone referred you to the Academy, please type their name here. If they are enrolled in the Academy, we credit them $100 toward their child’s tuition, for every family they refer. You can be rewarded as well. When you refer a family to us, be sure to ask them to include your name so that you can receive the $100 credit. There is no limit to the number of credits you can receive – up to covering all of your child’s annual tuition.