Print Form Complete all fields, print and fax to 1-888-321-2215.

Part 1: Student Information Part 3: Course Registration

Please fill in the course name and appropriate semester (.5 credit). Regular and Honors courses
First Name are $375 per semester. AP courses are $400 per semester. Use 2nd sheet if more space is needed.

Course 1 Sem. 1 Sem. 2 Full Course

Last Name
Course 2 Sem. 1 Sem. 2 Full Course
Date of Birth
Course 3 Sem. 1 Sem. 2 Full Course
Male Female
Course 4 Sem. 1 Sem. 2 Full Course
Grade Level
Course 5 Sem. 1 Sem. 2 Full Course
Email Address
Course 6 Sem. 1 Sem. 2 Full Course
Phone Number

Address Part 4: Payment Information

Please provide information regarding who will pay for the above courses by checking one of the
City, State, Zip following choices. Please Note: Students residing outside the US will be charged an
additional $25 per semester.

Part 2: School Information Self Pay (please fill in the credit card information below, or make check payable to
Florida Virtual School and mail to: 2145 Metro Center Blvd, Suite 200, Orlando, FL 32835)

Country District Paying

State Paying District or State Contact
State
Credit Card Visa Mastercard
School District Name
Card #
School Name
Exp. Date $ Amount Total

Name on Credit Card

Address

City, State, Zip

For help, please call Florida Virtual Global School at 407-513-3476 Email Address