PHHS New Enrollment Form
Is the student a resident of the South Madison Community School Corporation?
Anticipated date to start attending our school.
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DD
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Student's First Name:
Your answer
Student's Middle Name:
Your answer
Student's Last Name:
Your answer
Student's Suffix:
Your answer
Student's Birth Date:
MM
/
DD
/
YYYY
Student's Gender:
Student's Ethnicity:
Current Grade:
Does your child receive Special Ed or Speech services?
If Yes, please list the services:
Your answer
Home Phone:
012-345-6789
Your answer
Street1
Your answer
Street2
Your answer
City
Your answer
State
Zip
Your answer
Do you already have a Parent Portal login with South Madison Community Schools?
If Yes, please provide the username you use to log into Parent Portal:
Your answer
Who does the child live with?
Mother’s/Step/Guardian1 Name:
Your answer
Mother's/Step/Guardian1 email address?
Your answer
Father’s/Step/Guardian2 Name:
Your answer
Father’s/Step/Guardian2 Email Address:
Your answer
Submit
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