<p> Student Application Date: ______Grade: ______</p><p>Student Information Name: ______Date of birth: ______Original Year of Graduation: ______Number of Credits Earned: ______</p><p>Address ______Home Number: ______Cell Number: ______Do you have access to a computer at home? □ Y □ N Do you have internet access at home? □ Y □ N Email address: ______Do you participate in extra-curricular activities? □ Y □ N What? ______Do you work? □ Y □ N Where? ______</p><p>Parent Contact Information Parents, you may sign up to have a progress report automatically generated. Please provide your email address below and indicate how often you would like to receive an email. Email Address 1: Frequency: Weekly Daily Email Address 2: Frequency: Weekly Daily</p><p>Proposed Courses for Credit Recovery/Acceleration in Panther Academy (Core Classes Only) Note students accepted into Panther Academy begin with one course on a trial basis. After a 3-6 week trial period additional courses may be added if there is space, an educational need, and the student is making good progress.</p><p>1st Choice: ______2nd Choice: ______</p><p>Student statement of Need: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>Revised 6/2011 Student: Why do you feel the Panther Academy would suit your personal needs and goals better than CHHS? ______</p><p>______</p><p>______</p><p>______</p><p>Student: What changes and/or commitment are you willing to make to be successful in the Panther Academy? ______</p><p>______</p><p>______</p><p>______</p><p>Parent statement of Need: ______</p><p>______</p><p>______</p><p>______</p><p>Students selected to the program are those who are “at risk” of dropping out or have already dropped out of school. I understand the selection process and, if selected, I will follow the rules and regulations pertaining to Panther Academy.</p><p>Being enrolled in Panther Academy is a privilege. Students enrolled in the Academy must demonstrate the desire to complete courses, to attend school, to make good choices while at school in order to be a successful student and to graduate. Not following through with these requirements could result in being removed from the Panther Academy Program.</p><p>Students please read and initial below. ____ I understand that I must provide a pair of headphones; if I am not able to purchase a pair of headphones, a pair will be checked out to me. </p><p>_____ I understand that I must make academic progress in my Academy course. If progress is not made, then I will be changed back to a traditional class.</p><p>_____ I understand that I must be motivated to work independently and ask for help when I need it. It is my responsibility to complete my courses in a timely fashion.</p><p>______Parent Initial By initialing, I am indicating that I understand the expectations of the program and that my student must make progress in order to remain a participant in the Academy program.</p><p>Student Signature ______Date ______</p><p>Parent Signature ______Date ______</p><p>Revised 6/2011</p>