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Archdiocese of Miami Virtual Catholic School (ADOM-VCS)
Email any questions or concerns to Ms. Rebeca Bautista, principal, at
principal@adomvirtual.com
.
Thank you for your ongoing support of Catholic education.
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Email
*
Your email
Enrollment Form: Fall 2017
Is this your first time taking a course with ADOM-VCS?
*
Yes
No
STUDENT Last Name
*
Last Name will be used to create student account; username will be created, based on information included here.
Your answer
STUDENT First Name
*
First Name will be used to create student account; username will be created, based on information included here.
Your answer
Current Grade
*
12
11
10
9
8
7
6
Requested Start Date
*
MM
/
DD
/
YYYY
Requested End Date (latest date is 12/22/2017)
*
MM
/
DD
/
YYYY
Student Type:
*
Choose
Catholic School
Public/Charter School
Private School
Home School
Name of current school:
*
If Home School, enter the name of the curriculum provider/group or district.
Your answer
E-mail Address - Student
*
Your answer
Date of Birth - Student
*
MM
/
DD
/
YYYY
Gender - Student
*
Choose
Male
Female
Birth Country - Student
*
Your answer
Primary Language - Student
*
Your answer
Social Security Number - Student
*
SSN is used for identification purposes only - if you do not wish to share SSN, the student's date of birth will be used in a situation where a unique student identifier is requested. Enter either SSN or N/A.
Your answer
Mailing Address - Student
*
Only street address - city, state, zip code are separate entries.
Your answer
Mailing Address - Student
*
City
Your answer
Mailing Address - Student
*
State - two letter abbreviation
Your answer
Mailing Address - Student
*
Zip Code
Your answer
Race - Student
*
Mark all that apply - at least one is required.
American Indian / Native Alaska
Asian
Black
Native Hawaiian / Pacific Islander
White
Multi-Racial
Required
Are you, the student, a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of Race?
*
Required by Florida Department of Education and Archdiocese of Miami
Yes
No
Religion - Student
*
Choose
Catholic
Non-Catholic
Parent/Guardian Information
Enter "NA" if no information is available.
Parent/Guardian 1:
*
Choose
Father
Mother
Legal Guardian
PARENT/GUARDIAN 1 Last Name
*
Last Name will be used to create student account; username will be created, based on information included here.
Your answer
PARENT/GUARDIAN 1 First Name
*
First Name will be used to create student account; username will be created, based on information included here.
Your answer
Parent /Guardian 1 Email
*
Your answer
Parent/Guardian 1 Primary Contact Number
*
Your answer
Parent/Guardian 2:
*
Choose
Father
Mother
Legal Guardian
Student only has one primary parent/guardian.
PARENT/GUARDIAN 2 Last Name
*
Last Name will be used to create student account; username will be created, based on information included here.
Your answer
PARENT/GUARDIAN 2 First Name
*
First Name will be used to create student account; username will be created, based on information included here.
Your answer
Parent /Guardian 2 Email
*
Enter 'N/A' if student only has one primary parent/guardian.
Your answer
Parent/Guardian 2 Primary Contact Number
*
Enter 'N/A' if student only has one primary parent/guardian.
Your answer
Course Request
Courses - Use 'ENTER' after each course name)
*
Example: Algebra I/Semester 1, English III/Semester 2, Economics, World History/Full Credit
Your answer
A copy of your responses will be emailed to the address you provided.
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