Dolphin STEM Academy Online Private School Application

This form is the payment in full option. If you want to use the monthly payment option, click here to complete the monthly payment application.

Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender and Race/Ethnicity*

Student's email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country*

Grade Level Applying for*

Anticipated start date (at least 5 business days are needed for registration) *

Your School District and Last School Attended*

Student's STEM area(s) of interest*

Are you a NCAA Prospective Student Athlete and in need of NCAA approved courses?*

NoYes, I'm a NCAA Prospective Student Athlete

What is your sport as a student athlete?

Does this student have an IEP or require special education services? If yes, please explain in detail.*

Additional comments/info about the student

Please upload a current photo of the student (headshot), immunization record or exemption letter, student's birth certificate, and school records (transcripts, report cards, standarized tests, etc).*

Browse Files

Enter your child's social security number (it will be hidden on the form)

Coding Platform for Coding Club (click all that apply, but only one is available per month):

Minecraft & Roblox (CodaKid)Python & UnityCode CombatNot interested in the Coding Club

FL RESIDENTS ONLY: The state of Florida requires 2 items: (1) Health Exam completed on Form DH3040 which has been completed within the last 365 days; and (2) proof of immunization which must be completed on Form DH 680 by a Florida physician. For students with a vaccination exemption, the exemption must be completed on Form DH 681 by your Florida county health department. Please upload forms 3040 and DH 680 or 681 if your child is a Florida resident only. For more information, please visit www.floridahealth.gov/programs-and-services/immunization/schoolguide.pdf

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Do you want to enroll an additional student?*

Yes, I want to enroll an additional student.No, I do not want to enroll an additional student.

2nd Student's Name

First NameLast Name

Birth Date

MonthDayYear

Gender and Race/Ethnicity

Student's email

example@example.com

Grade Level Applying for

Anticipated start date (at least 5 business days are needed for registration)

Your School District and Last School Attended

Student's STEM area(s) of interest

Does this student have an IEP or require special education services? If yes, please explain in detail.

Are you a NCAA Prospective Student Athlete and in need of NCAA approved courses?

NoYes, I'm a NCAA Prospective Student Athlete

Additional comments/info about the student

Please upload a current photo of the student (headshot), immunization record or exemption letter, student's birth certificate, and school records (transcripts, report cards, standarized tests, etc).

Browse Files

Enter your child's social security number (it will be hidden on the form)

Do you want to enroll an additional student?

Yes, I want to enroll an additional student.No, I do not want to enroll an additional student.

!!!!NOT USED ANYMORE; Coding Platform for Coding Club (click all that apply, but only one is available per month):

!!!!NOT USED ANYMORE; FL RESIDENTS ONLY: The state of Florida requires proof of immunization or exemption for all Florida residents. The immunization records must be completed on Form DH 680 by a Florida physician. For students with a vaccination exemption, the exemption must be completed on Form DH 681 by your Florida county health department. Please upload form DH 680 or 681 if your child is a Florida resident only. For more information, please visit www.floridahealth.gov/programs-and-services/immunization/schoolguide.pdf

Upload Files

3rd Student's Name

First NameLast Name

Birth Date

MonthDayYear

Gender and Race/Ethnicity

Student's email

example@example.com

Grade Level Applying for

Anticipated start date (at least 5 business days are needed for registration)

Student's STEM area(s) of interest

Your School District and Last School Attended

Does this student have an IEP or require special education services? If yes, please explain in detail.

Additional comments/info about the student

Please upload a current photo of the student (headshot), immunization record or exemption letter, student's birth certificate, and school records (transcripts, report cards, standarized tests, etc).

Browse Files

Enter your child's social security number (it will be hidden on the form)

!!!NOT USED ANYMORE; Coding Platform for Coding Club (click all that apply, but only one is available per month):

!!!NOT USED ANYMORE; FL RESIDENTS ONLY: The state of Florida requires proof of immunization or exemption for all Florida residents. The immunization records must be completed on Form DH 680 by a Florida physician. For students with a vaccination exemption, the exemption must be completed on Form DH 681 by your Florida county health department. Please upload form DH 680 or 681 if your child is a Florida resident only. For more information, please visit www.floridahealth.gov/programs-and-services/immunization/schoolguide.pdf

Upload Files

We don't spam and we don't sell info! We use contact information to get in touch with you about your requested service and programs at Dolphin STEM Academy.

Parent/Guardian Name*

First NameLast Name

Your Relationship to the Student (mother, father, grandmother, aunt, friend, etc.):*

Phone Number*

Area CodePhone Number

Email*

Enter the email address to receive login information.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country*

Would you like to add another parent/guardian to the student's school account and profile?*

YesNo

Would you like to receive our promotional emails for events, news, promotions, and more?*

Yes!No

How did you hear about Dolphin STEM Academy?*

FacebookGoogleOther/Referral (Please enter referral name below)Other

2nd Parent/Guardian Name

First NameLast Name

2nd Parent/Guardian's Relationship to the Student (mother, father, grandmother, aunt, friend, etc.):

2nd Parent/Guardian Phone Number

Area CodePhone Number

2nd Parent/Guardian Email

Enter the email address to receive login information.

2nd Parent/Guardian: Would you like to receive our promotional emails for events, news, promotions, and more?

Yes!No

Does your child have a parent or grandparent who is an active duty or retired member of the US armed forces and eligible for our military discount?

NOYES

Upload your proof of military status, and DELETE/HIDE any confidential information. This step is required for the discount codes to appear in the next step.

Browse Files

Military Discount

If your student has an active duty or retired US armed service member as a parent or grandparent, your child qualifies for a discount.

Enter the coupon code below on the coupon section of the registration and payment.

For 1 student enrollment, use code: military1

For 2 student enrollment, use code: military2

For 3 student enrollment, use code: military3

REGISTRATION & PAYMENT:*

Private School Enrollment - 2 Semesters discounted FULL YEAR ENROLLMENT$4,599.00

2 Semesters, full school year. Discounted tuition for payment in full. Sibling discount will be automatically applied when you select the number of students to enroll in the Quantity box.

Total # of STUDENT ENROLLMENTS
Item subtotal:$0.00

Enter coupon

Total $0.00

PAYMENT AND REFUND POLICY

We want you to be happy! Payment is required prior to the beginning any courses/assessments. Refunds are available for written cancellations received within 7 calendar days after purchase. All refunds are subject to a $250 cancellation processing fee and pro-rata usage fee. Cancellation requests must be emailed and must include the student's full name, date of birth, enrollment courses, and parent/guardian applicant's name and phone number. To protect the interests of families, refunds will only be issued to the same payee and using the same payment method as the original purchase payment was made.

AGREEEMENT

By signing and submitting this form, you acknowledge that you are an adult age 18 years or older and are completing this form on behalf of a child/minor in your care to participate in our private school programs and services. You agree to pay the required course fees for the programs and services. Furthermore, you agree to the Terms of Service and also the COPPA declaration below.

Federal COPPA Regulation

Dolphin STEM Academy utilizes several computer software applications and web‐based services, operated not by this school, but by third parties such as CodeNow, Kahoot, Google Workspace for Eduation, Adobe Creative Cloud, and more. In order for students to use these programs and services, certain personally identifiable information, generally consisting of the student’s name and email address, must be provided to the web site operator. Under a federal law entitled Children’s Online Privacy and Protection Act (COPPA), these websites must provide parental notification and obtain parental consent before collecting personal information. For more information on COPPA, please visit http://www.ftc.gov/privacy/coppafaqs.shtm. Each website operator is bound by COPPA to maintain the confidentiality of the information collected. They are also required to post a privacy policy describing their practices. A full list of the operators in use by the district, as well as links to their respective privacy policies may be found on our SIS portal and our school website at: https://dolphinstemacademy.com/legal/

How will this affect my child?

Dolphin STEM Academy will be able to create accounts on educational websites and apps for your child to use at school. The apps and websites used vary in content, but include learning and practicing academic skills such as phonics, reading, writing, communication, math, and more.

COPPA permits a school to consent to the collection of this information on behalf of all of its students, thereby eliminating the need for individual parental consent given directly to each individual website operator. This form, when completed below and on file with the school, will constitute consent for your child to make use of the programs and services listed. It will also constitute consent for our school to provide personally identifying information for your child to the operators listed. We only provide the minimum information needed to operate any of the programs and services. This information may include first name, last name, nickname, gender, race/ethnicity/nationality, Student ID #, email address, username, grade level, date of birth address, social security number, medical/health information, siblings, and parents.

CURRICULUM POLICY

An enrollment advisor will contact you to discuss our extensive list of courses and provide an orientation to the program. Private school courses are generally available between August and May of the school year, however custom school years may be created as needed. Please contact us with any questions.

Signature*

Use your mouse/cursor to sign electronically.

FULL PAYMENT - PREPAID DISCOUNT

Student Information

2nd Student Information

3rd Student's Information

Parent/Guardian Info

2nd Parent/Guardian Info

Tuition and Fees Payment

Submission of Application