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PHHS New Enrollment Form
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* Required
Is the student a resident of the South Madison Community School Corporation?
Yes
No
Clear selection
Anticipated date to start attending our school.
MM
/
DD
/
YYYY
Previous/Current School Attended?
*
Your answer
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:
*
Choose
Male
Female
Is this student Hispani/ Latino?
*
Yes
No
Student's Race: (Select One or More)
*
American Indian
Asian
Black
Native Hawaiian / Pacific Islander
White
Required
Current Grade: (for 2022-2023 School Year)
*
Choose
9th
10th
11th
12th
Does your child receive Special Ed or Speech services?
*
Yes
No
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
*
Choose
IN
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Your answer
Do you already have a Parent Portal login with South Madison Community Schools?
*
Yes
No
If Yes, please provide the username you use to log into Parent Portal:
Your answer
Who does the child live with?
*
Choose
Parents
Mother
Father
Mother/Step Father
Father/Step Mother
Grandparents
Guardian
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
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