HSDL Registration Form



 
This form must be completed by a School Official. 
 
Please fill out the following information as accurately as possible. You will receive a confirmation of your request in an email. If you do not get a confirmation email, you may have entered some information incorrectly. Please contact hsdl@kirkwood.edu to confirm that your request went through.

The start date for a class begins immediately following registration. Please register your student when they are ready to begin the class. 

Student Demographic Information (All Fields Required)
Last Name
 		First Name
 		Middle Initial
Street Address
 		City
 		State
Zip Code
 		Date of Birth
 		Gender
Primary Phone Number
 		Primary Email Address
 		 
School District Information for Billing (All Fields Required)    
Name of School District
 		Phone Number
 		Address
City
 		State
 		Zip Code
School Information for Curriculum Delivery
(for packet classes only) 		   

Do you need a text book?
 yes     no 
 
Name of School
 		Address
 		City
State
 		Zip Code
 		 
1. School Contact or Mentor
This is a required field. 

Name of person who receives: 
1. Request confirmation email
2. Username and password to mentor in Apex
3. Final Grade 		Email Address
This is a required field. 





  		Phone Number
This is a required field. 





 
2. School Contact or Mentor

Name of person who receives: 
1. Request confirmation email
2. Username and password to mentor in Apex
3. Final Grade 		Email Address  





  		Phone Number  





 
     
3. Test Proctor or Coach
This is a required field.
Name of person who receives: 
1. Tests 
2. Weekly progress email
3. Proctor must be 18 or older 		Email Address
This is a required field.





  		Phone Number
This is a required field





 

Course Information - Use dropdown menu
Must choose at least one course
Course 1:  
Course 2: 
Course catalog link: https://www.apexlearning.com/digital-curriculum/courses/catalog
*Not all classes in this link are currently offered. 

SCED Finder link: https://nces.ed.gov/scedfinder/Home/Browse

Kirkwood HSDL can no longer accept payments directly from students or parents. All courses will be billed direclty to the school district. It is recommended that students sign up for no more than two (2) courses at a time. 

For local schools, you should list the person to receive final grades and notifications of difficulties that a student may be having in online/correspondence courses. For schools at a distance, you should list the person(s) that you would like to receive weekly notifications of progress in online courses and the person that will be emailed the written tests.

Terms and Conditions for School District
By signing this registration form, the school district accepts responsibility for payment of all fees related to the course, responsibility for granting student credit upon completion of the course (Kirkwood HSDL will send a recommended grade to the proctor), providing or approving an acceptable proctor, and monitoring student progress during their four (4) months to complete the course. Students needing accommodations should submit paperwork to the HSDL office prior to starting courses. 

School Official Signature and date:  If the School Official Signature and date is left blank, this registration will not be processed. By signing and dating this document, you are agreeing to all Terms and Conditions as stated above and will be billed for this registration. 

Terms and Conditions for Student
By checking this box, I understand that I need to have a valid email address and complete at least one assignment weekly. I authorize Kirkwood Community College to provide information to the school and to the email addresses provided regarding enrolment status, grades and credit. I acknowledge that I have four (4) calendar months from the date of enrollment to complete the course, and if not finished in that time, I agree to take an incomplete in the course. I understand that these courses are for High School credit only. 

Student Signature on File     
Parent Signature on File (if student is not 18)
                  

If your student has an IEP/504 for which they would like accommodations (modifications are not allowed), contact our High School Distance Learning Staff at HSDL@kirkwood.edu.