2018-19 Application
Check if applying for:
Student Name: *
(First, Middle, Last)
Your answer
Address: *
Street, PO Box, City, Zip
Your answer
DOB: *
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Birth City & State: *
Please list what is on the birth certificate
Your answer
Gender *
What grade are you in? *
Ethnicity/Race: (*Check what applies) *
Required
Home School (name of district currently attending): *
Your answer
Open Enrolled: *
Mother/Guardian: *
Your answer
Address: if different from student (Mother/Guardian)
Your answer
Home Phone (Mother/Guardian):
Your answer
Cell Phone (Mother/Guardian): *
Your answer
Work Phone (Mother/Guardian):
Your answer
E-mail (Mother/Guardian):
Your answer
Father/Guardian: *
Your answer
Address: If different from student (Father/Guardian):
Your answer
Home Phone (Father/Guardian):
Your answer
Cell Phone (Father/Guardian): *
Your answer
Work Phone (Father/Guardian):
Your answer
E-mail (Father/Guardian):
Your answer
KCCC Lab Choices 1st Choice *
KCCC Lab Choices 2nd Choice *
KCCC Lab Choices 3rd Choice *
Student Signature: *
By typing your name, you agree to the terms and conditions of the application.
Your answer
Custody: *
Student Lives With: *
If a divorce or guardianship situation exists, we must have a certified full copy of the order or decree. This is per State of Ohio Law (ORC 3313.672) and the Missing Children's Act.
If divorced, who has residential custody for school purposes?
If Legal Court Placement, a copy of the court papers showing which school district is responsible for educational costs is required.
How did you hear about the Knox County Career Center?
I approve this application and request the release of transcripts and IEPs to the Knox County Career Center. In addition, I give permission to release testing scores for the student named above to KCCC. This district will use these scores to determine whether the student needs to retake any parts of testing in order to fulfill Ohio state graduation requirements and to place the student in the appropriate classes. The student information will only be disclosed to school officials and authorized representative. This district will not re-disclose the information.
Parent's / Guardian's Signature: *
Your answer
Date: *
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KCCC does not discriminate on the basis of race, color, national origin, gender orientation, disability, age, religion, ancestry or other protected classes in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups.Jeff Lavin, KCCC Director, has been designated to handle inquires regarding the non‐discrimination policies and Title IX. Elaine Robinson, KCCC Principal, has been designated to handle inquires regarding Section 504.
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