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Required Enrollment Form Step 1 of 5 20% Student InformationName* First Last Birthdate* MM slash DD slash YYYY Gender* Male Female Other Grade LevelSelect your current grade level...6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeHome Phone Number*Cell Phone NumberEmail Address* Enter Email Confirm Email Address* Street Address Address Line 2 City State ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent InformationParent Information #1 (Main Contact)Relationship*MotherFatherStepmotherStepfatherGrandmotherGrandfatherLegal GuardianOtherPrimary 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 NumberParent Information #2RelationshipMotherFatherStepmotherStepfatherGrandmotherGrandfatherLegal GuardianOtherPrimary Contact? Yes No Name First Last Home Phone NumberCell Phone NumberParent 2 Email Address Enter Email Confirm Email Please enter the best email to communicate with a second parent or guardian.Parent Information #3RelationshipMotherFatherStepmotherStepfatherGrandmotherGrandfatherLegal GuardianOtherPrimary Contact? Yes No Name First Last Home Phone NumberCell Phone Number Academic InformationMy Academic Plan is To:*Graduate Through Alta IndependentTransfer Credits To My Current High SchoolMy 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 #1School Name* School Phone NumberSchool Fax NumberCounselor / Advisor School Address Street Address City State ZIP / Postal Code For Transferring Students - Previous School #2If you are planning getting a diploma from Alta Independent, you will need to provide information about all previously attended schools.School Name School Phone NumberSchool Fax NumberCounselor / Advisor School Address Street Address City State ZIP / Postal Code For Transferring Students - Previous School #3If you are planning getting a diploma from Alta Independent, you will need to provide information about all previously attended schools.School Name School Phone NumberSchool Fax NumberCounselor / 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?*Alta Independent StaffOnline SearchSocial MediaCoach, Teacher, or Program StaffReferral from a FriendHard Copy FlierMy School CounselorOtherWhich social media platform?*FacebookInstagramLinkedinBlogReddit or other ForumsName of Referral:* Name of Counselor:* Other Source Details:* PaymentOnce 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!Additional Comments:CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Contact Us to Request More Information First Name* Last Name* Email* Enter Email Confirm Email Phone*ProgramChoose from the following...Full or Part Time EnrollmentIndividual CoursesPartnership ProgramsCredit CaptureAdult DiplomaCOPA - Utah Conservatory of the Performing ArtsSummer SchoolSelect a program so we can have the appropriate staff member answer your questions.MessageCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.