PIF Pathways 2018/2019

Get READY to CHANGE YOUR LIFE.

You can upload your ID and Transcript or fax to TSA later.
Pay in Full or Select Payment Plan *

I Paid in Full $490
Which Partner School Referred You? If none, write NONE *
What is your previous school district *
Student Information
Are you an International Student

Yes No
Full Name *

First Name Middle Name Last Name
Birth Date

Month Day Year
Date of Birth *

/ Month / Day Year
Age *
Social Security Number
Select One

Male Female

Ethnicity *

	Yes	No
Hispanic

Race *

	Yes	No
American Indian or Alaska
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or More Races

Email Address *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

- Area Code Phone Number
Cell Phone Number

- Area Code Phone Number
Education History
Previous or Current High School
City and State
Last Grade Attended *
Have you requested Transcript to be sent to us? *
Do you work?You can earn up to 3 High School Elective Credits for Working

Yes No

Custodial Parent or Guardian for under 18

Name
Street Address
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number
E-mail used to send link to monitor your child
Does the student want to Walk at Graduation in June 9, 2019? Graduation Fee is $180.00, which includes Cap, Gown, Tassel, 19 Graduation Pictures and 5 tickets. You will pay a little each month toward graduation. *

Yes No
Graduation For Gown- Height and Weight
RELEASE FORM

I, the undersigned, grant Texas Success Academy Distance Learning Private High School permission to use my letter(s) or/and likeness in photograph(s)/ video(s) in any and all of its publications and in any and all other media, whether now known or hereafter existing, controlled by Texas Success Academy Distance Learning Private High School, by that name or another name, I will make no monetary or other claim against Texas Success Academy Distance Learning Private High School for the use of the letter(s) or photograph(s) and/or video(s).

This is for testimonials, success stories and website photos.
Release Form *

Yes, I agree to the Release form for my testimony or photos or videos No, I do not agree to give a testimony or be used in any photos or videos
Upload your documents here

Uploaded documents need to be in a PDF Form or you may fax them to 1-877-330-2606.
Picture ID
Supported format: PDF Max file size: 5MB
Transcript
Supported format: PDF Max file size: 5MB
IEP (Special Education)
Supported format: PDF Max file size: 5MB
Please check the boxes. You are required to complete the following We will email a handbook to you: *

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I understand that entering my name in the box below constitutes a legal signature confirming that I acknowledge and agree to allow Texas Success Academy to enroll me or my student into school. I also agree to the terms and conditions.
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