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Prairie Delta Program
Application for Admission
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Name *
Date of Application *
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/
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YYYY
Student Address *
Date of Birth *
MM
/
DD
/
YYYY
Current Year in School *
What special services do you have? *
Required
Number of High School credits completed *
Current GPA
Guardian's Name(s) *
Guardian's Address (if different)
Guardian's Telephone Number *
Student's Telephone Number *
Guardian's E-mail Address *
Student's E-mail Address *
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