Wichita eSchool Application Form
High
School
Instructions: Please print the following information.
School Year/Semester
___________________________________________________________
Student’s Full Legal Name:________________________________________________________
Student’s
Address:_______________________________________________________________
City:_______________________State:__________________
Zip Code:______________________
Home Phone________________________________________
Birthdate:___________________
e-mail
address:__________________________________________________________________
Father/Guardian
Name:_______________________________Work#:_______________________
Cell
#:____________________e-mail address:__________________________________________
Mother/Guardian
Name:_______________________________Work#:_______________________
Cell#:____________________e-mail
address:__________________________________________
School District you
attend:____________________ School Phone:_______________________
Address:____________________________City, State
Zip________________________________
---------------------------------------------------------------------------------------------------------------------------------------
School Administator
Information:
Yes, this
student may take a Wichita eSchool course for credit. Date:_________________
School Administrator Name
print: _______________________Signature:___________________
Courses:
Name of School Facilitator who will administer Semester Final___________________________
Phone number:_________________________________
e-mail address:________________________________________________
Please attach payment for courses & textbook rental –Receipt will be mailed upon receiving form & payment.
Return this form & fees to
Wichita eSchool
Wichita Public Schools
412 S. Main
Wichita, Ks. 67202
316.973.5181