Broady Academy - H.S. Enrollment Form
Program
*
High School Diploma
Purpose for Diploma
*
Community College
4 Year School
Trade School
Work
Military
Other
Student First Name
*
Student Last Name
*
Student's Email
*
The email typed here will be used to sign into the student portal
Parent/Guardian Email
example@example.com
Student's Phone
*
This phone number will be used as the primary contact number for the student
Date of Birth
*
Age
*
Sex
*
Male
Female
Ethnicity
*
African American
Hispanic
Caucasian
Asian
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous School Attended
*
Previous School City/State
*
Last School Grade Completed
*
Emergency Contact Name
*
First Name
Last Name
Referred by
If you were referred by a friend, please type their first and last name here
Husky Get Started Session
By checking the box below, I am confirming that I understand that I may be required to complete National Percentile assessments within the first 5 days of enrollment. I also may be required to participate in an Independent Learning Plan Zoom session. I agree to work a minimum of 5 hours per week on my assignments.
*
I understand
Terms & Conditions
By checking the box below, I am confirming that I have verified with my school, employer, or other institution that they accept the E.L. Broady Academy diploma and that there are no refunds after 5 working days.
*
I accept the Terms and Conditions
Student Digital Signature
*
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Date Signed
*
-
Month
-
Day
Year
Date
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LIFE RESUME GUIDE
Employer 1: Job Title
Dates of Employment
Responsibilities/Tasks
Employer 2: Job Title
Dates of Employment
Responsibilities/Tasks
Do you have children?
YES
NO
Which social media accounts do you have?
Facebook
Instagram
Twitter
Other
Have you ever been a member of a gym, YMCA, or sports team?
YES
NO
Hobbies
Training Courses
Foreign Languages (check all that apply)
English Speaking
English Writing
Spanish Speaking
Spanish Writing
Other
Attend church regularly?
YES
NO
We also award Family Consumer Science credit if you have at least 5 of the items below. Check all that apply:
Driver's License
Apartment/House Lease
Car Insurance
Bank Account
ID Card
Passport
Social Security Card
Gym Membership
Debit Card
Gov't Support Letter
Library Card
Proof of Employment
How would you like to pay?
*
$199 DOWN PAYMENT
$349 FULL PAYMENT
After click
Continue
below, you will be redirected to the student portal to submit your payment.
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Continue
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