Guardians please enclose a copy of your Driver's License and Social Security card.

If your child has a social security card and immunization records, please provide that also. If your child does NOT have a social security card or immunization record, please provide a notorized statement as to your religious objection to such.

If you have any correspondence from authorities in your area, please provide a copy for our records as you deem appropriate. Telephone contact beforehand is recommended if you have special circumstances.

STUDENT INFORMATION

Student name:

Phys & Mailing address:

SS # and DOB:

Phone:

Fax:

Cell:

Email:

GUARDIAN INFORMATION

Guardian 'A' Name:

Phys & Mailing address:

SS# and DOB:

Phone:

Fax:

Cell:

Email:

Previous physical address (if less than 5 years at present address):

Employer name, address, phone number:

Guardian 'B' Name:

Phys & Mailing address:

SS# and DOB:

Phone:

Fax:

Cell:

Email:

Previous physical address (if less than 5 years at present address):

Employer name, address, phone number:

BACKGROUND INFORMATION FOR STUDENT AND GUARDIAN

Experience/Education:

Student experience: This would include student's previous educational experiences along with schools attended. This should be as exhaustive as possible and include anything you feel is important in our consideration. Please type or print this in the form of a summary, outline, or resume and attach it to this application.

Guardian A & Guardian B experience: Same info as above in the same format. Be sure to list employment, volunteer work and community affiliations. Political and/or religious affiliations do not have to be listed; however, your application will not be declined due to any political or religous affiliations. Your civic involvement is regarded as a positive trait irregardless of your specific affiliations.

OTHER CONSIDERATIONS

Would the Guardian consider being a consulting mentor for other home educators? ( ) yes; ( ) depends, lets talk; ( ) not now.

If someone other than the guardian proposes to be this child's mentor, please include the same info for them. In this case, we will have at least 3 summaries (child, guardian(s) and mentor). The mentor should also include their physical and mailing addresses, social security number and date of birth.

If you are forming an educational Coop, please include the eduational and employment resume for all parents in the Coop attached to their own child's application.

"I hereby authorize PROGRESSIVE NETWORK ACADEMY to verify my past and present educational records and background information. I also authorized PROGRESSIVE NETWORK ACADEMY to verify the same records of the above listed child. It is understood that a copy of this form shall act as the original."

BY (sign & date):______________________________

BY (sign & date):______________________________