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High School ENROLLMENT APPLICATION
Pearblossom Academy, P.O. Box 439, Bogue Chitto, MS 39629
Please provide copy of birth certificate, a small photo of student for our records, and transcript of High School credits earned.
These items can be scanned and emailed to us at [email protected] or faxed: 601-658-0264 or mailed to our office. Remember to check the box under Additional Fees if the program is being sent outside the US; $120 will be charged for shipments outside the USA even if the box is left unchecked.
Parent's Full Name: Student's Full Name:
Address: Date of Birth:   Check if enrolling 2 or more students (Note: You will need to fill out a separate application for each student.)
City:
State:
Zip:
Email Address:
Student Gender: Male   Female
Student Ethnicity:
(Select ONLY ONE)		 White (Caucasian)
African American
Hispanic
Filipino
American Indian
Asian/Pacific Island
Other, specify:
Important Notice for students in CALIFORNIA ONLY: All students located in CALIFORNIA who are enrolling in any grade (9 through 12) must complete the online Private School Affadavit form which is available at this link Calif. Dept. of Education Private School Affadavit Form. Failure to file this form could result in mandatory attendance at a local Public School.
Phone
Student has book Young People Ask? Yes   No
Alternate Phone:
Check if you have Internet Access  No Internet
Place in the desired grade:   High School Grades
Check if 2nd Semester Only 9th, 10th, 11th, or 12th1
9th*
 10th*
 11th
 12th
Tuition1 $875 $875 $875 $775
Book Fee2 $200 each grade
Total Amount $1075 $1075 $1075 $ 975
Down Pmt.3 $475 $475 $475 $375
No. of Monthly Payments4 8 x $75
1Tuition does NOT include (a) the Book Fee which is also required, (b) an additional $120 fee for shipments outside the USA; $100 for Science Lab shipment outside the USA, and (c) Science Labs if required (see footnote #3 below). The student may work at his or her own pace, generally taking 9 to 12 months to finish; however, an additional $50 fee is incurred for each additional month the student is enrolled beyond the 12th month. For 2nd Semester Only 9th, 10th, 11th, or 12th--must submit transcripts that confirm 1st Semester was completed and passed.
2If student re-enrolls and all text books have been returned by student and received by Pearblossom in good condition, then book fee will be waived.
3The credit card used to make the initial down payment will be set up on monthly "autopay" until balance has been paid in full.
4Payments must reach us by the 15th of the month or a late fee of $20.00 will be incurred. *Students that plan to attend a University (and some Colleges) may take a science lab in 9th and another in 10th which may be done at a local college or online.
 
Select 4 different electives in order of your preference. If your first selections are unavailable, we will use the other lower-priority elective selections as alternatives. If no electives are selected, Pearblossom will send any available electives.  Elective Descriptions
For 11th or 12th Grade:
If student last attended Pearblossom, Check this box:
Previous School Name:

Fax No.: 		Address:
City:
State & Zip:
Additional Fees:
Required Postage/Handling Fee of $120 for shipping to CANADA, MEXICO, and other addresses outside the 50 States of the USA
     
Foreign Language:
Student will learn desired language from experienced instructors from Online Global Classrrom--receiving immediate feedback, ensuring they master the skills necessary to reach their language goals. Pricing is minimum of $240 (payable to Online Global Classroom) and more information is available at this link: Online Language Costs
Spanish      French      Italian      German      Chinese      Japanese      Korean      Russian      Amerian Sign (ASL)      Other
Hands-on Art Electives      $75 Drawing Program      $250 Intro to Quilting      $125 Advanced Quilting      $125 12th Grade Only Graduation Kit
72-Hours of 1:1 Tutoring available at link.
Total of Additional Fees: $   If paying by CHECK or Money Order, print this form and send with check - DO NOT PRESS SUBMIT. Note: Check or Money Order must be drawn on a USA bank--not a foreign or Canadian bank--even if funds are shown in USA Dollars. Credit Cards from other countries are acceptable.
15- or 16-digit Charge Card Number: 3 to 4-digit CCV, CVC, or CV2 Code:
ONLY for American Express cards: Download the required form, then scan and email the completed and signed form to [email protected] or fax to 601-835-1718 or mail to: Pearblossom Academy, P.O. Box 439, Bogue Chitto, MS 39629
Check ONLY if you are making a down payment AND desire to make monthly payments using the specified card number. Card will be charged on the 8th of each month until balance is paid in full.
Name on Card:     Expiration Date (mm/yy):     Amount to Charge: $ (initial payment; please remember to add Additional Fees)

Tuition Fee and Enrollment AGREEMENT: I acknowledge that accreditation does not guarantee that Pearblossom Academy credits will be transferable or acceptable to other educational institutions. Pearblossom Academy's accreditation MSA (Middle States Association) is, however, recognized by the United States Department of Education. In addition to a diploma, colleges and other educational institutions may require entrance exams such as GED or SAT (or other such tests) as a part of their enrollment process. Also, a $50.00 per month additional fee is incurred for each additional month the student is enrolled beyond the 12th month. I, (type full name of parent/guardian), the undersigned, hereby authorize Pearblossom Academy to obtain a release of student information, including transcripts, from previously attended schools. Should payment remain delinquent in excess of ninety (90) days the student shall automatically be dis-enrolled and an additional $50 processing fee will be required to reinstate enrollment. A $15.00 service charge will be incurred on all returned checks. An $85 fee will be incurred for each replacement text book or DVD. A maximum limit of 12 months is allowed for the enrolled student to complete each grade. A complete refund, less $100.00 shipping/handling or processing fee, will be issued upon cancellation within thirty (30) days from date of receipt of books and upon return of all books and materials. Payments must reach our offices by the 15th of each month or a late fee of $20 will be incurred. Please allow 3-8 weeks for delivery. The parent/guardian is responsible for enrolling the student in Science Labs if such are required by the college or university that the student plans to attend. The parent/guardian is solely responsible for contacting the college/university the student plans to attend--to determine the high school courses required for entrance. Pearblossom Academy's cumulative liability to undersigned or the student or any other party for any loss or damages resulting from any claims, demands, or actions arising out of or relating to this Agreement shall not exceed the enrollment tuition fees paid for the curriculum provided. In no event shall Pearblossom Academy be liable for any indirect, incidental, punitive, special, or consequential damages, including legal fees, lack of transferability of credits, loss of (a) data by means of computer software or USA mail, (b) profits or revenues, (c) employment or education opportunities, whether based in contract, tort or otherwise, even if Pearblossom Academy has been advised of the possibility of any such loss or damage. I understand that Pearblossom Academy shall have the right to legal action for nonpayment of tuition and fees, and the undersigned will be responsible for all costs of collection, including court expenses and reasonable attorneys' fees. Since the attendance laws vary from state to state, Pearblossom Academy urges the undersigned to check state attendance laws; Pearblossom Academy is not responsible for ensuring compliance with state or local truancy laws; that is the responsibility of the undersigned. Furthermore, the undersigned is responsible for the expense of returning and insuring the books and accomplishing any required state testing. Regardless of state testing requirements, Pearblossom Academy highly recommends the student take a nationally normed test at the parent or guardian's expense which can often be accomplished coincident with public school testing. Accreditation and associated requirements are subject to change without notice. Any student found by Pearblossom Academy to be cheating on tests will be disenrolled immediately with NO refund or credits issued. Any prior "Book Deposit" agreed to in prior year's agreement is now considered as a "Book Fee" as discussed above. This Agreement constitutes the entire agreement between the undersigned and Pearblossom Academy and supersedes any prior agreements, representations, proposals, or understandings, whether oral or written, with respect to the subject matter of this Agreement. I have read and understand this Agreement as evidenced by my name and date below.
Signature (Type Your Full Name):
Date (mm/dd/yy):What is your age:
   
Pearblossom Academy, Inc.--Quality Education Programs for Grades 9-12