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Utah InfoCenter

Apply for the 2021-22 Program

Our tuition-free, personalized distance education program is available to home-based Utah residents between the ages of 5-18.

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Please complete all required fields.

Parent First Name

Parent Last Name

Parent Phone

Parent Email

Parent Email Again

Student First Name

Student Last Name

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

Student First Name

Student Last Name

Student Grade Level (age) as of September 1, 2021 Student Grade Level as of 09/01/2021

Has student ever been diagnosed with a learning disability or ever qualified for Special Education Services through an IEP or 504 plan (including Speech Therapy)?

No

IEP (additional documents will be required)

504 (additional documents will be required)

Please review and submit this form as part of the standard application process.

Does this student plan to complete the requirements to earn a Utah high school diploma (schedule flexibility is limited)?

Yes

No

City of Residence

Student(s) agrees to adhere to all program policies and requirements, including participation in state testing. Review details at mytechhigh.com/utah.

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