MSAISnet Student Enrollment Form

Enrollment will be processed once a completed form and appropriate payment is received.

Student Name

First Name

Last Name

Student Email Address

School Name

Mentor Name

First Name

Last Name

Mentor Email Address

Mentor Phone Number

Personal phone is preferred.

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Course or Program Selected

Please indicate the course(s) or program selected using the title(s) listed in the MSAISnet Course Catalog. Example: Algebra I

Semester

All 1.0 credit MSAISnet courses are distinct by .5 credit semester portions. Select the appropriate Semester for the course enrollment, Semester A, Semester B, or Both. For a .5 credit course, select N/A.

Course Type

Select Credit Recovery if enrolling into one of the CR courses. Otherwise, select Non-CR/New Credit.

Instructional Format

Please indicate if you desire for the course to be Content + Instruction ('with instruction') or Content Only ('without instruction').

Proposed Start Date

Propose a start date for the enrollment; Semester A or a one semester enrollment. Note- a student will not be enrolled until both the enrollment form and payment have been received.

YYYY

Proposed End Date

Propose an end date for the enrollment. Semester A or a one semester enrollment.

YYYY

Proposed Start Date - Sem B if applicable

If selected "Both", please provide a proposed start date for the Semester B portion of the enrollment.

YYYY

Proposed End Date - Sem B if applicable

If selected "Both", please provide a proposed end date for the Semester B portion of the enrollment.

YYYY

School Administrator Granting Permission for Enrollment

Today's Date

YYYY

MSAISnet Student Enrollment Form

If mailing form and payment, please mail to:

MSAISnet 4820A Poplar Springs Drive PMB 264 Meridian, MS 39305