Genium/TIVA Counseling Enrollment Form

Student Name

First Name

Last Name

Student Email Address

Student Full Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Date of Birth

YYYY

Student Phone Number and Skype

Parent or Guardian Name

First Name

Last Name

Parent or Guardian Email Address

Parent or Guardian Phone Number and Skype

Learning Coach Name

First Name

Last Name

Learning Coach Email Address

Learning Coach Phone Number and Skype

ACT Score (if applicable)

SAT Score (if applicable)

Name and Full Mailing Address of Student's Traditional School

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Today's Date

YYYY

Student's Extracurricular Activities

Please provide a full listing of the student's current and past extracurricular activities including athletics, clubs, community service, etc.

Student's Future Plans

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