Student First Name:*

	Student Last Name:*

	Student ID#:*

	Grade Level for 2011 - 2012 School Year:*
	--Please Select--9101112

	Does the student have an IEP:*
	--Please Select--Yes No

	Student Guidance Counselor:

	Indicate which nine weeks you plan to take the course(s):*
	1st 9 weeks (Semester 1)   2nd 9 weeks (Semester 1)   3rd 9 weeks (Semester 2)   4th 9 weeks (Semester 2) a.

	Are you taking this course as Credit Recovery?
	--None--Yes No

	The Credit Recovery option is only available if you have already failed a course. Credit Recovery courses will receive a pass/fail final grade on your transcript. All course work will be based on an initial prescriptive test. If you are requesting a letter grade on your transcript, you must register for a traditional cyber course.

	What course(s) are you requesting to take through the Central Valley Cyber Service program? Please see the Program of Studies for course descriptions and numbers.
	Course #   Course Name a.     b.     c.     d.     e.

	Where do you plan to complete your virtual education courses?*
	--Please Select--HomeSchoolBoth Home and School

	Do you attend Beaver County Career and Technology School?
	--None--Yes No

	Do you have a computer with High Speed Internet access at home?
	--None--Yes No

	Is a parent or guardian at home throughout the school day?
	--None--Yes No

	Do you plan or already participate in activities or athletics on the Central Valley Campus?
	--None--Yes No

	If Yes (to question 14), please indicate:
	Fall  Winter  Spring

Students enrolled full-time in the Cyber Service program must be actively engaged in their on-line course work for a minimum of 3.5 hours prior to participating in extracurricular activities or practices on that day. Any Central Valley cyber course will be calculated for eligibility purposes. Students will be expected to remain in Cyber Service for the full semester they are registered in the course. Students that request to drop Cyber Service classes must complete a schedule change request form in the guidance office and the request must be approved by the building principal. Students will receive a percentage grade and QPA for each course completed. Students who choose to enroll in the Central Valley Cyber Service will receive a diploma from Central Valley School District upon successful completion of their required graduation credit along with meeting all other graduation requirements. Student’s progress will be emailed daily and a progress report will not be mailed. Any student taking a semester course all year will have their grade recorded during the third and fourth marking period. Students are required to attend a minimum of 3.5 hours a week per class and follow all school policies and procedures. Students will be expected to follow the internet technology policy of Central Valley School District. Student handbook, announcements and additional resources are located on our district webpage: http://www.centralvalleysd.org I understand and agree to all policies and procedures of Central Valley School District.

	I understand and agree to all policies and procedures of Central Valley School District.

	Student Signature* Student signature acknowledges that you have read and will abide by the terms of the contract.
	Indicates approval

	Parent Signature* Parent signature acknowledges that you have read and will abide by the terms of the contract.
	Indicates approval

	Home Phone:

	Parent Cell Phone:

	Parent Email:

	*Daily progress reports will be sent to this email address. You may add additional email addresses separated with a semi-colon.

	Where did you learn about Central Valley Cyber Program?*