Student & Course Information

Student

Student

Mizzou Academy 306 Clark Hall Columbia, MO 65211 Toll Free 855-256-4975 | Fax 573-884-9665

mizzouacademy@missouri.edu mizzouacademy.missouri.edu

Course Registra on

Student Full Legal Name: _______________________________________________________________________________________

First

Middle

Last

Birth Date: _______/________/_______ Legal Gender: _______ (M/F) Race: __________ Ethnicity: _________________

Month

Day

Year

(required)

(Op onal)

(Op onal)

Residen al Address: ___________________________________________________________________________________________

City: _______________________ State: _____________ Postal Code: _______________ Country : __________________________

Telephone: __________________ Student email address (required): _________________________ Ci zenship: __________________

Country of Birth: _____________ Maiden/different legal name: _______________________ Highest Grade completed? __________

Have you previously enrolled in a Mizzou Academy course? Yes No

If yes, please indicate year enrolled:___________

Is the student registered or intend to be registered with the NCAA or NAIA? Yes

No

Athle c #:________________

Have you been admi ed to the University of Missouri High School Diploma program?

Yes

No

Are you a homeschool student (not a ending a tradi onal school)?

Yes

No

Please provide name of school a ending: ______________________________________ Website: ____________________________

Course(s) you are requesng:

Course Title

1st Half?

(Fall Semester)

2nd Half?

*Counselor approval: Print

(Spring Semester) name here ______________

(signature)

(signature)

(signature)

(signature)

Academic

Academic

Guardian

Guardian

*Homeschool and Mizzou Academy students--no signature needed

How did you learn about Mizzou Academy: Academic Advisor/Counselor

Internet Search

Mizzou Academy Website

MOCAP Other: __________________________

Name of Guardian (if student under 18) : ________________________________________________________________________________ Contact informa on: Phone (____) - ____ - ______ Email: _________________________________________________________ Residen al Address (if different than student's) : ____________________________________________________________________________ Name of Guardian (if student under 18) : ________________________________________________________________________________ Contact informa on: Phone (____) - ____ - ______ Email: _________________________________________________________ Residen al Address (if different than student's) : ____________________________________________________________________________

Tui on cost for each course is $500* + $20 paper applica on fee that will be placed on student's account. *Discounts and addi onal fees are listed on the website at: Tui on and Fees

Please allow 1 week processing me a er applica on is received. Students and guardians will have login informa on sent to the emails listed above. Full payment is required before access to course(s) is permi ed. FERPA and other state and federal statutes and regula ons apply. Ques ons? Contact our Student Support Services: 1-855-256-4975

01/06/2020

Payment

Payment

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