MHSAP-Enrollment-Form-2018-02
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MHSAP Enrollment Form NEW2018-2019
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Parent(s)/Guardians(s) Name
AddressCity Zip
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Primary Phone #
Secondary Phone #
Parent Work Phone #
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Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship to Student
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(Not parent)
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Resident School District
Resident County
Parent email address
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Student Information:
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First NameMiddle NameLast NameM/FBirthdate
(00/00/00)
Age on 9/15/1818-19 GradeRace*IEP/504
History**
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*Race: Enter AS for Asian, PI for Hawaiian or other Pacific Islander, WH for White, BL for Black or African American, HS for Hispanic or AI for American Indian/Alaskan Native.
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**IEP/504 History: Refer to the Student Services section below.
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Custody Status
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¨ Check here if any custody issues we need to be aware of. (Please include legal paperwork if box is checked.)
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Pre-school History (new students only)
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If the child attended pre-school anywhere, please list the school, city, state here:
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Medical Concerns/Allergies (Please list them here or on the reverse side of this form)
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Dual Enrollment:
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Indicate if you wish a student dual enrolled and whether for AC (Academic), EX (Extracurricular), SpEd (Special Education Services, SYP (Senior Year Plus Options) and/or interest in Internships/job shadows and/or Kirkwood Career Edge Academy
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Student's NameDual Enrolled for:
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Student Services:
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List below any students who are receiving, or have received in the past, any student services (IEP, 504, speech-or other- therapy). Also list the school district and beginning/end dates for the services.
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Student's NameServices received/where/when
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Office Use Only:
OE _____ Orientation _____ Website _____ St D/b _____ Mail List _____ P/Sch _____ Lib. _____ Sup. Teacher ________________
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