Now enrolling for the 2021-22 school year. Please complete this form to start the first step of the application process. Pacific Virtual Learning Application Form We're excited you've chosen Pacific Virtual Learning for your child's education! Please complete this form to begin the enrollment process. The form takes under five minutes to complete. All sections must be completed in order to submit your information. Partially completed forms cannot be saved. If you have more than one child, please complete a form for each child.Enrollment type desired with Pacific Virtual Learning*Full-timePart-timeStudent's Name* First Middle Last Student's Date of Birth* Date Format: MM slash DD slash YYYY Birth CountryStudent's Gender*MaleFemaleAddress* Physical Street Address (No PO Box) Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Grade going into (K-8)K12345678Does your student have an active IEP for Special Education Services?YesNoName of Last School AttendedDates Attended Last School*What language did your child first learn to speak?*What is your child's primary language?*What language does your child use the most at home?*What race(s) do consider your child?*Guardian 1* First Last Guardian 1 Phone*Guardian 1 Alternate Phone*Guardian 1 Email* Enter Email Confirm Email Guardian 1 Relationship to Student*Guardian 2 First Last Guardian 2 PhoneGuardian 2 Alternate PhoneGuardian 2 Email Enter Email Confirm Email Guardian 2 Relationship to ChildMilitary Parent of Guardian Affiliation-Washington State Legislature has mandated that data on students from military families must be collected as stated in RCW 28A.300.507. (please mark all that apply) No parent or guardian currently serving as a member of the U.S. Armed Forces, Reserves of the U.S. Armed Forces or Washington National Guard. Yes a parent/guardian is a current member of the active duty U.S. Armed Forces. Yes a parent/guardian is a current member of the reserves of the U.S. Armed Forces. Yes a parent/guardian is a current member of the Washington National Guard. Yes more than one parent or guardian is currently either a member on active duty in the U.S. Armed Forces, Reserves of the U.S. Armed Forces or Washington National Guard. No Response/Refused to state. McKinney-Vento Program-Please mark all that apply Shelter Unsheltered-living in a car, park, campsite, trailer park, bus/train station, abandoned building or other location not ordinarily used as sleeping accommodations. Unaccompanied Youth-youth not living with a parent or guardian Doubled Up-sharing housing of other persons due to loss of housing, economic hardship or similar reason Motel/Hotel Awaiting Foster Care Temporary Placement-child temporarily placed with relative or guardian Migrant Transitional Housing None of the Above Please enter your full name and date below. By entering your name and date below, you are stating that you have the legal authority to make educational decisions on behalf of the student you are registering.*
