PIF Pathways 2019/2020

Get READY to CHANGE YOUR LIFE.

You can upload your ID and Transcript or fax to TSA later.

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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

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Full Name *

First Name Middle Name Last Name

Birth Date

Month Day Year

Date of Birth *

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Age *

Social Security Number

Select One

Male Female

Ethnicity *

	Yes	No
Hispanic

Race *

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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 $100.00, which includes Cap, Gown, Tassel, 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

Picture ID

Supported format: PDF Max file size: 5MB

Transcript

Supported format: PDF Max file size: 5MB

IEP (Special Education)

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Please check the boxes. You are required to complete the following We will email a handbook to you: *

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Additional Comments or Questions

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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