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EDISON ACADEMY REQUEST FORM
This form is for current BPS students aged 17+, who are over-aged and under-credited for their grade, seeking enrollment in the Edison Academy Evening Program.
STUDENT'S NAME
*
First Name
Last Name
STUDENT'S DATE OF BIRTH
*
-
Month
-
Day
Year
Date
STUDENT ID NUMBER
CURRENT SCHOOL
*
Please Select
BROCKTON HIGH SCHOOL
BROCKTON VIRTUAL LEARNING ACADEMY
CHAMPION HIGH SCHOOL
RE-ENGAGEMENT CENTER
PROMISE COLLEGE & CAREER ACADEMY
GRADE in 25-26
*
Please Select
6
7
8
9
10
11
12
REASON FOR REQUEST
*
PARENT/GUARDIAN NAME
*
First Name
Last Name
PARENT/GUARDIAN EMAIL
example@example.com
PARENT/GUARDIAN PHONE
*
Please enter a valid phone number.
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARENT/GUARDIAN SIGNATURE
*
UPLOAD PARENT/GUARDIAN PHOTO ID
*
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