Action Sports Academy Application

Do you need to take or retake the SAT or ACT?*

YesNo
ACT Score
When did you take the ACT? (mm-dd-yyyy)
SAT Score
When did you take the SAT? (mm-dd-yyyy)
TEFOL Score
When did you take the TEFOL? (mm-dd-yyyy)

Mother's Name *

First NameLast Name
Mother's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Phone Number*

Area CodePhone Number
Mother's Email*
example@example.com
Father's Name*

First NameLast Name
Father's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Phone Number*

Area CodePhone Number
Father's Email*
example@example.com
Main Point of Contact*

MotherFatherBoth

Insurance Provider
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Policy Number
Group Number

Emergency Contact:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
Relationship of Emergency Contact:*

My Products

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty: