Application & Registration Forms Night, Summer, or Virtual School

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I. Applicant Information
Date: _________________________________________ HLA Campus Location: Fort Bend North Humble Clear Lake Katy

Student Information:
Student name: ___________________________________________________________________________________________________ Last First Middle Student Date of Birth: _____________________________ Student Home Address: ___________________________________________________________________________________________ Street City State Zip Student Email:_________________________________________ Is this your first time attending HLA? Yes Grade Entering: 9 10 11 12 No High school graduates are not eligible to attend HLA courses No Student Cell Phone: _____________________________________

Has student ever been suspended or asked to leave any school? Yes Goals after high school graduation (please check one): Pursue Career Attend 2-year College

If yes, explain ________________________________________________________________________________________________ Attend 4-year College or University

Are you interested in pursuing NCAA athletics in college? Yes No *** All students must read and sign the NCAA waiver *** Prospective college athletes should be aware that HLA does not determine NCAA eligibility or NCAA criteria for recognizing high school courses and disclaims responsibility for students determined ineligible by NCAA based upon their HLA course selection.

Current School Information

Current High School Name _____________________________ Counselor Phone ______________________________________ Current School Counselor ________________________________ Counselor Email Address _________________________________

Contact/Family Information:
Parent Name: _________________________________________ Relationship to Child: __________________________________ Home Address: _______________________________________ ______________________________________________________ Home Phone: _________________________________________ Cell Phone: ___________________________________________ Email: ________________________________________________ Parent Name: ___________________________________________ Relationship to Child: ____________________________________ Home Address: _________________________________________ ________________________________________________________ Home Phone: ___________________________________________ Cell Phone: _____________________________________________ Email: __________________________________________________

How were you referred to our school? (name of source if possible) _________________________________________________________________________________________________________________
@2012 Houston Learning Academy

Application & Registration Forms Night, Summer or Virtual School

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II. Course Registration

Please select your requested courses from the current Schedule of Classes and write them in the space below. Make sure that the courses you select are offered at your grade level and location. Your sponsor and HLA administrator must approve and sign at the bottom of the form. School Year: ________________ Available Sessions Subject Evening Fall Evening Spring Summer I AM Summer I PM Summer II AM Summer II PM Course Title Summer III AM Summer III PM Virtual Session

Course Number

Student Signature Parent/Guardian Signature Current School Counselor Signature HLA Signature

Student Name (print) Parent Guardian Name (print) Current School Counselor Name (print) HLA (print)

Date Date Date Date

III. Financial Information & Payment

Total Amount Due: $ _________________ Total Amount Paid: $ _________________ Check: #________________

Credit Card Payments

MC/Visa #: ______________________________________________ Exp. Date: _______________________

I hereby authorize Houston Learning Academy to charge the above reference credit card, in a one-time lump sum of $____________________. I understand that the authorized payment is in advance of services rendered.

Credit Card Authorization Signature

Name on Credit Card (print)

Date
@2012 Houston Learning Academy

Application & Registration Forms Night, Summer or Virtual School

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IV. Night School, Summer School and Virtual Course Agreement

Registration: Registration is on a first come, first served basis. Registration form, fees and signatures by all parties are mandatory for enrollment. Enrollment constitutes acceptance of HLA school policies. Full payment for each class must be included. Check, money order or credit card for the amount of the course will secure registration. The last day to register without incurring the late fee ($25) is one week prior to the beginning of that session. Changes, Cancellations & Refunds: There is a $100 course/session change fee and a $150 cancellation fee for course changes/ cancellations prior to the beginning of the session. Once the session starts, there will be no refunds for cancellations. No refunds will be made for students that are dismissed because of attendance, suspension, or inappropriate behavior. If HLA cancels a course for any reason, we will make a full refund. No credit/ refund will be given for holidays, professional in-service days, student absences or illnesses, or HLA closures due to emergency or inclement weather. Attendance: Attendance is mandatory. Due to state regulations, any student who does not have at least 90% attendance for each class in a session will be dropped from the class without refund. HLA is a closed campus. Students must stay in their assigned class. For reasons of security, parents, police or the sheriffs department may be notified if a student leaves campus without permission. Books: Books are provided for the use of students but remain HLA property. Books must be returned at the end of the session. Students are responsible for damaged or lost textbooks. Grades and Final Exams: Grades will only be granted when all course requirements are met. Incomplete grades are not granted. Students must complete all work assigned by the teacher, or zero credit will be given. One-half credit will be granted for each subject passed. The final exam is 25% of the grade. Students must successfully pass the final exam with a grade of 70% or higher to receive credit for the class. No final exam retakes will be offered. Final exams will be completed on the assigned date and time. Grade reports will be mailed or electronically sent to the student and his/her high school of record at the end of the session. NCAA Disclaimer: Prospective college athletes should be aware that HLA does not determine NCAA eligibility or NCAA criteria for recognizing high school courses and disclaims responsibility for students determined ineligible by NCAA based upon their HLA course selection. Student Records: All student records remain the property of the HLA, except as may otherwise be provided by law. HLA will send academic records and confidential recommendations to schools you have authorized, and you will not seek access to confidential recommendations and evaluation materials. Further, you release HLA and our staff from any and all liability resulting from or pertaining to the furnishing of recommendations and records. Use of Photographs, etc.: You authorize us to use your childs photograph or appearance in any advertising or other media. Illness/Emergency: I authorize my child to have emergency service and be transported to an area hospital if necessary. Attire: The attire of all students must be neat, clean and modest. The judgment of the appropriateness of attire rests with the principal. Blue jeans, shorts, t-shirts, and sandals are acceptable. The following are unacceptable: tank or halter tops, strapless tops, spandex, cut-off shorts, questionable printing/slogans, and obvious distractions. Substance-Free Campus: Possession of any controlled substance or drug (prescription/nonprescription drugs, alcohol, or tobacco) is cause for immediate expulsion without refund. A no-smoking ban extends to within 500 feet of the campus in all directions. For reasons of safety, parents, police or sheriffs department will be notified of any students that are found in possession of or suspected of being under the influence of any of the above. Student Conduct/Dismissal: Disciplinary action, up to and including dismissal, will be taken immediately for a students disrespect, defiance, profanity, disruption, verbal or physical abuse, cheating, truancy, theft, defacing school property, malicious mischief, reckless driving on campus, unauthorized departure, failure to follow HLA rules and other conduct or acts deemed unacceptable by HLA or law enforcement. All cell phones and pagers must be turned off and kept out of sight during class time. Food and drinks may not be brought into, or consumed in, class. Students cannot distribute or solicit items, pamphlets, events or services. We reserve the right to suspend or dismiss students in our sole discretion for the best interest of the school. Computer/Internet Use: Use of the Internet will be closely monitored by the teachers to ensure adherence to established HLA guidelines. HLA computers will only be utilized for the sole purpose of instruction. Students are not allowed to visit social networking sites, gaming sites or check personal email. Students are prohibited from reconfiguring computer settings or bringing in personal storage devices. Cars/Parking Lot: Drivers and vehicles in the immediate campus area, including visual sight, are under HLA rules and regulations. Speed limit in the HLA/area parking lot is 5 MPH. Students should enter the facility immediately upon drop off or arrival. Unsafe driving in the parking lot is cause for dismissal without refund. NSF Checks: A $30 fee will be assessed for NSF checks. An NSF check will result in the student being placed on financial suspension and grades will not be released until restitution is made. You will pay all costs of collection, including attorney fees. Name and signature certifies that all submitted information on any HLA application and paperwork is true and correct. Enrollment constitutes acceptance of HLA school policies.

I agree to the above policies, including the obligation to pay for all tuition and fees, and in all events be responsible for the financial obligations of my child including any lost or damaged property. I authorize my child to have emergency service and be transported to an area hospital if necessary.

Student Signature Parent/Guardian Signature

Student Name (print) Parent/Guardian Name (print)

Date Date

@2012 Houston Learning Academy

Application & Registration Forms Night, Summer or Virtual School

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V. NCAA Eligibility Disclaimer and Liability Release

Disclaimer
The designation of Houston Learning Academy (HLA) courses as College Preparatory (CP) in the list of HLA courses is intended to assist students who are prospective student-athletes to select courses which will be recognized by the National Collegiate Athletic Association (NCAA) in its determination of NCAA eligibility. Courses designated as Texas (TX) fulfill the State of Texas requirements, (TEKS) Texas Essentials Skills and Knowledge Standards, for attaining a Texas High School diploma, but may not fulfill NCAA eligibility requirements. NCAA may recognize only CP courses, not TX courses in determining eligibility. HLA does not determine NCAA eligibility or NCAA criteria for recognizing high school courses and disclaims responsibility for students determined ineligible by NCAA based upon their HLA course selection. The most current and accurate information can be obtained by visiting the NCAA website www.ncaaclearinghouse.net or by calling 877-262-1492.

Liability Release
By my signature below, I, the parent of ________________________________, an HLA student; or I, _________ _______________________, an HLA student eighteen (18) years of age or over, hereby forever release and discharge HLA and its parent company, Nobel Learning Communities, Inc. (NLCI) and their officers, directors, parent companies, subsidiaries, stockholders, employees, agents and representatives from any and all claims of whatever nature arising from or related to said students course selections for NCAA eligibility purposes and/or eventual NCAA eligibility determination, including, but not limited to, contract claims, equitable claims and any and all claims arising under any federal, state or other governmental statute or common law.

Signature

Print Name

Date

@2012 Houston Learning Academy

Application & Registration Forms Night, Summer or Virtual School

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VI. Pre-Enrollment Modification Inquiry Form

Would your child need assistance and/or modifications to the Nobel Learning Communities (NLCI) programs and services in order to fully participate in NLCIs programs and services? ( YES or NO - circle one) Any requests for assistance and/or modifications must be made to this schools Principal, Assistant Principal and/or NLCIs ADA Compliance Officer. An enrollment decision will not be made until such request has been decided upon by NLCIs ADA Compliance Officer.

School Name

School #

Name of Student

Program/Grade

Parent/Guardian Signature

Parent/Guardian Name (print)

Date

Parent/Guardian Signature

Parent/Guardian Name (print)

Date

HLA Principal Signature

HLA Principal Name (print)

Date

This Nobel Learning Communities, Inc. school does not discriminate on the basis of disability in its provision of educational programs and services.

@2012 Houston Learning Academy