UT ONLINE HIGH SCHOOL APPLICATION FOrM

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					                                                                                                                                                                      FORM AVAILABLE ONLINE
                                                                                                                                                                      www.utk16.org/form/uths



                   K-16 Education Center
                   C o n t i n u i n g & I n n o v a ti v e E d u c a ti o n




UT ONLINE HIGH SCHOOL APPLICATION FOrM
(Complete application and send with payment and copies of all official high school transcripts.)
  PERSOnAl InFORMATIOn (Please print in ink.)                                                                                 PAYMEnT

                                                                                    Male            Female         $200 nonrefundable Application Fee

  UT EID (leave blank if unknown)     Birthdate (mm-dd-yyyy)                     Check one                               Money Order

                                                                                                                         Check #
  name:
            Last                                               First                                 M.I.          Driver’s License #                                       State

                                                                                                                    Please do not staple check to enrollment form.
  Address:                                                                                                          Make checks payable to The University of Texas at Austin.
            Street                                                                                   Apt. #
                                                                                                                         Credit Card
                                                                                                                            VISA                      MasterCard
            City                                                               State                 ZIP
                                                                                                                            Discover                  American Express
  Phone: (              )                                        (        )                                        Number
             Home Telephone                                     Business Telephone                                 Exp. Date

  E-mail:                                                                                                          Print Cardholder’s Name
  SCHOOl InFORMATIOn
  name of last School Attended:
  School Address:
                            Street                                                                              City                                       State                    ZIP
   Phone:                                                                                                       Approximate last Date Attended:
  I HEARD ABOUT THIS PROGRAM FROM (Choose all that apply.)
       Advertisement            Brochure/Catalog           Friend              Counselor, Principal or School     Web            Other

  I am interested in UT High School because (fill in the blank):


  STUDEnT AGREEMEnT
  In signing this application, I understand that the courses I will take are from the UT K–16 Education Center at The University of Texas at Austin and that I will abide by the UT K–16
  Education Center’s policies and procedures. I also understand that successful completion of the state exit-level exams (TAKS) will be required for graduation. If I am an out-of-state
  resident, I agree to call The University of Texas High School at (866) 361–UTHS (8847) or (512) 471–4808 to arrange for exit-level testing prior to graduation. If I am applying for or receiving
  a collegiate athletic scholarship, I understand it is my responsibility to contact the NCAA regarding the requirement for the core curriculum. I understand that status as a full-time student
  would require concurrent enrollment in four one-semester courses and completion of at least eight assignments per month (total). I also certify that the information included on this
  form is correct.

  You must enroll in a course within the first three months of acceptance to the program. If you do not enroll during the first three months, you are dropped from the program and will
  have to reapply for admission.

  Parent’s Signature (If student is age 17 or under.)                                                                                                 Date

  Applicant’s Signature                                                                                                                               Date

  FOR STUDEnTS WITH DISABIlITIES AnD/OR STUDEnTS REQUESTInG SPECIAl ACCOMMODATIOnS
           not Applicable
           Applicable: I have read and understand the policy regarding special accommodations on the UT K–16 Education Center
           Web site (www.utk16.org).

  SUBMISSIOn InSTRUCTIOnS

                To register by mail:
                                                                                                                                                                   For more information:
              UT K–16 Education Center                                  To register by fax:                            For more information:
                                                                                                                                                                    call 1 (866) 361-8847
                   P.O. Box 7700                                          (512) 232-6414                                www.utk16.org/uths
                                                                                                                                                                     or (512) 471-4808
               Austin, TX 78713-7700

0710

				
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posted:8/6/2011
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