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(888) 423-9192

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Required Enrollment Form

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Student Information
Name*
First Last
Birthdate*
MM slash DD slash YYYY
Gender*
- Male
- Female
- Other
Grade Level
Home Phone Number*
Cell Phone Number
Email Address*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP / Postal Code Country

Parent Information
Parent Information #1 (Main Contact)
Relationship*
Primary Contact?
- Yes
- No
Parent Email Address*
Enter Email Confirm Email

Please enter the best email to communicate with the parent or guardian.
Name*
First Last
Best Contact Number*
Cell Phone Number
Parent Information #2
Relationship
Primary Contact?
- Yes
- No
Name
First Last
Home Phone Number
Cell Phone Number
Parent 2 Email Address
Enter Email Confirm Email

Please enter the best email to communicate with a second parent or guardian.
Parent Information #3
Relationship
Primary Contact?
- Yes
- No
Name
First Last
Home Phone Number
Cell Phone Number

Academic Information
My Academic Plan is To:*
My Post High School Plans Are To:*
- Enroll at a College or University
- Enter the Workforce
- Enlist in the Military
- Currently Unknown
Do you intend to participate in NCAA Athletics?*
- Yes
- No
ATTENTION: If you are planning on receiving an NCAA Athletic Scholarship and are taking courses for credit recovery from Alta Independent, you will need to verify that the course you are taking is NCAA approved.
Do you have an IEP or 504 Plan
- Yes
- No
- Unknown or Not Aware of an IEP
Current or Previous School #1
School Name*
School Phone Number
School Fax Number
Counselor / Advisor
School Address
Street Address City State ZIP / Postal Code
For Transferring Students - Previous School #2
If you are planning getting a diploma from Alta Independent, you will need to provide information about all previously attended schools.
School Name
School Phone Number
School Fax Number
Counselor / Advisor
School Address
Street Address City State ZIP / Postal Code
For Transferring Students - Previous School #3
If you are planning getting a diploma from Alta Independent, you will need to provide information about all previously attended schools.
School Name
School Phone Number
School Fax Number
Counselor / Advisor
School Address
Street Address City State ZIP / Postal Code

Are you applying to receive credit through one of our Specialized Programs? (Example: Mountain Bike Club, Dance, Performing Arts, Other Extracurricular Programs)*
- Yes
- No
Which one(s)?*
- Dance
- Performing Arts Academy
- Mountain Bike Club
- Other
Dance: Name of Studio or Company?*
Performing Arts Academy: Name of Academy or Team?*
Mountain Bike Club: Name of School or Team?*
Other: Name of Program?*
Are you a student continuing with Alta Independent from Residential Treatment Center or Wilderness Program?*
- Yes
- No
Name of Program:*
How did you hear about us?*
Which social media platform?*
Name of Referral:*
Name of Counselor:*
Other Source Details:*

Payment
Once the enrollment form is filled out and submitted, go to the "Pay Online" tab on the top of the home page and submit your payment for the appropriate program. All payments are fully refundable within the first 30 days. No Credits will be issued until payment is received. Thank you for your interest in Alta Independent!
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(888) 423-9192

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