Genium/TIVA Counseling Enrollment Form

Student Name *
Student Name
Student Full Mailing Address *
Student Full Mailing Address
Student Date of Birth *
Student Date of Birth
Parent or Guardian Name *
Parent or Guardian Name
Learning Coach Name *
Learning Coach Name
Name and Full Mailing Address of Student's Traditional School *
Name and Full Mailing Address of Student's Traditional School
Today's Date *
Today's Date
Please provide a full listing of the student's current and past extracurricular activities including athletics, clubs, community service, etc.
Provide a description of the student's career goals, including a summary of current interests and hobbies. Provide a description of the student's college goals, specifically concerning US attendance plans. Perform an internet search and provide three to six college names that interest the student based on available areas of study, location, or other factors important to the student. The college selection tool provided by the College Board found at https://bigfuture.collegeboard.org/college-search is useful for this purpose.
Send Student's Academic Record/Transcript
Send electronic copy of student's academic record/transcript from grade 9 and above to counselor@theindependentvirtualacademy.com
Send Future Course List
Send electronic listing of courses that the student has yet to take at the traditional school, but will take prior to graduation to counselor@theindependentvirtualacademy.com