Student Application

Thanks for your interest in attending Wellmont Academy. Please fill out this application and we will notify you of the next steps. Please note, a $25 non-refundable application fee is required for submission of all applications.

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Information Meeting Code*
Have you attended an Information Meeting?

Attending a Wellmont Academy Information Meeting will help you get the most out of your experience in the application process. Once you have attended an Information Meeting, you will receive a code to open this application. Please contact us at info@wellmontacademy.com to inquire about upcoming Information Meetings so that you can get started!

Please enter the information meeting code:

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Main Contact Email*
Enter Email Confirm Email
Student Information
Current Grade Level*
Name*
First Last
Gender*
DOB*
Place of Birth*
Student ID Picture*
Please choose a picture for the Student ID
Accepted file types: jpg, jpeg, png.
Address Information
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Last address of student if different from above
Street Address Address Line 2 City State ZIP Code

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Parent/Guardian Information
Father's Name*
First Last
Father's Employer
Father's Occupation
Father's Phone Number*
Father's Email*
Mother's Name*
First Last
Mother's Employer
Mother's Occupation
Mother's Phone Number*
Mother's Email*

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Spiritual Information
Pastor or Small Group Church Leader's Name
First Last
Pastor/Leader's Phone Number
Length of Time Having Attended This Church
Parent's Statement of Faith*
Briefly state your faith beliefs as specifically as possible.

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References
Reference 1*
Please list the name of someone (non-family) who knows you and your child well.
First Last
Phone*
Reference 2*
Please list the name of someone (non-family) who knows you and your child well.
First Last
Phone*

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Emergency Contacts
Emergency Contact 1*
Person other than parent/legal guardian who is to be contacted in case of emergency. This person must be local and from a separate household than Emergency Contact 2.
First Last
Relationship*
Phone*
Emergency Contact 2*
Person other than parent/legal guardian who is to be contacted in case of emergency. This person must be local and from a separate household than Emergency Contact 1.
First Last
Relationship*
Phone*
Medical Information
Name of Insurance Company
Policy Number
Policy Number OLD - DO NOT USE
Doctor's Name*
First Last
Doctor's Phone Number*
Recommended Hospital
Please list any medical concerns or psychiatric care we should be aware of. If none, please type "N/A".*
Please list all student allergies. If none, please type "N/A".*
Birth Certificate
Accepted file types: jpg, gif, png, pdf.
Please upload a copy of your child's birth certificate. *This is not required to complete this application.

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School Information
Desired School Entrance Date*
Private or Flex Student Enrollment*
- I plan on signing up my child as a Privately enrolled student.
- I plan on signing up my child as a Flex student.
Are you interested in signing your student up as a Private or Flex student with us? Privately enrolled students enjoy the following benefits: We keep track of all records, including grades and transcripts; year-end testing is included in your fee; private students are eligible to receive guidance counseling from our school guidance counselor; private students are eligible to receive a high school diploma from us upon graduation. By May 1st of this 2018, all diplomas moving forward are scheduled to be accredited diplomas. *The cost for Privately enrolled student services per year is $250. Flex Students enjoy the following benefits: parents keep track of all records, portfolios, and grades, including transcripts; parents are responsible for year-end testing; Flex students are eligible to receive a homeschool high school certificate upon graduation.
*School Attendance History*
This field displays data from applications prior to 5/28/2017 and is not on the current application.
School Attendance History*
School Name Date Started Attending Length of Attendance in Years

Please list all previous schools that your child has attended.
Recent Evaluation Score, Standardized Assessment or Report Card
Drop files here or

Accepted file types: doc, docx, pdf.
If available, please attach a copy of the student's most recent Evaluation, Test or Report Card. This helps us better serve your student. If you are unable to provide adequate documentation, your student will be required to complete an standardized assessment, administered by Wellmont's Testing Department, prior to enrollment, for an additional fee of $75.
Parent Statement for Enrollment*
Please give a brief but comprehensive statement of your reasons for applying to Wellmont for your child.
How did you hear about Wellmont?*
Application Process Agreement*
Upon receipt of this application, we will call you to schedule a family interview with a member of our staff. Acceptance to Wellmont is determined by our staff and is a matter of prayer. We will notify you of acceptance via email, beginning March 1st. Do you agree to this application process?
Deposit Information*
If your family is accepted to Wellmont, you will receive an email of acceptance, as well as a login to our online platform with directions for completing the rest of your registration forms. Upon receipt of these forms, a member of our staff will contact you to come to our office. There, you will complete your student's course placement and a payment agreement. At this time, your non-refundable $250 deposit will be due. You may pay by check, cash, money order, or Paypal (terms and conditions of Paypal apply). This deposit MUST be paid to hold your child's place. Do you understand and agree to these terms and conditions?
Agreement to abide by the rules of Wellmont Academy*
As parents and prospective students, we agree to abide by the rules of Wellmont Academy. We understand that at any time, for any reason, Wellmont may choose to terminate our student's enrollment, making all payments and fees non-refundable if they see fit.
Notice of Rights
Wellmont Academy of Tampa Bay, Inc. admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of it's educational policies, admissions policies, scholarship and load programs and athletic and other school-administered programs.
Application Fee*
Price: $25.00
Payment Method*
- Credit Card
- Paypal
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Name
This field is for validation purposes and should be left unchanged.

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School Name	Date Started Attending	Length of Attendance in Years

Student Application

Step 1 of 7

Student Information

Address Information

Parent/Guardian Information

Spiritual Information

References

Emergency Contacts

Medical Information

School Information

Notice of Rights