Individual Class(es) PIF Form 20/21

Individual Classes

Enroll and Pay
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Need NCAA Clearance

Yes No
Student Name

First Name Last Name
First Name *
Last Name *
Grade Level *
Date of Birth *

Month Day Year
Social Security *
Gender *

Male Female

Ethnicity *

	Yes	No
Hispanic

Race *

	Yes	No
American Indian or Alaska
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or More Races

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail
Have you taken the prerequisite for this class?

Yes No

Please provide the Course name and Code (i.e Spanish I Semester A/B or Spanish I Semester Aand B) *

	Course name	Course Code
Course 1
Course 2
Course 3

Parent Information *

First Name Last Name
Parent E-mail *
Phone Number *

Area Code Phone Number

Please provide your school information to send your credits.
Name of School *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date School Needs Your Transcript

Month Day Year

Pay for your Individual Class(es) Below:

Registration is $100.00 plus your tuition.

Individual Class Fees

1/2 Credit (or 2 Quarters Hrs) = 0.50 (1/2 credit) $150.00

1 Credit (or 4 Quarters Hrs) = 1.00 Full Credit $300.00
Parent / Guardian Type Name to Enroll Your Child *

First Name Last Name
Upload your Parent Phot ID or Fax to TSA
Enter Total Amount: *
Transcript Amount: *

Amount Due *

USD Tuition and Fees .30 + 2.9%

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Amount Charged
Should be Empty: