PLC Application for Admission

If you are interested in being a part of the Douglas County Performance Learning Center, please fill out the PLC Application for Admissions online form. An incomplete application will not be considered. The Parent Consent form MUST be submitted along with the Student application for consideration. Click here to access the Parent Consent form or click on the form located on the PLC page.

PLC Application for Admission

Student Information

Student's Full (Legal) Name:

First:  Middle:  Last: 

Student's Full Address:

Please include Street, City, State, & Zip Code:      

Is this your mailing address:      If no, please specify: 

Home #:      Parent Cell #:  

 


Student Biographical Information

Preferred Name:   Student email address: 

Date of birth:   Age:   Gender: 

Ethnicity: 

Student resides with:   If you chose guardian, specify relationship: 

If you chose Group Home, provide the following:  Name of group home:   

Contact Name:    Contact #: 

Number of adults in the household:   Number of unrelated adults in the household: 

Number of children in the household:   

Ages of children in the household: 0-5  6-10 11-15 16-18

Is the student a parent or pregnant:   If yes, age of child or due date: 

Does the student work:   If yes, where:   Weekly hours: 

 


Parent/Guardian Information

Name of Parent/Guardian 1:   Cell #: 

Employer:   Work #:   Email: 

Name of Parent/Guardian 2:   Cell #: 

Employer:   Work #:   Email: 

Emergency Contact:   Relationship to student: 

Emergeny Contact #: 

 


Student Academic and Extracurricular Information

Have you attended a performance learning center:   List grade level(s): 

Current School:   Last grade completed: 

Check the areas that currently apply to the student: IEP    504 Plan     SST

List any extracurricular activities that you are involved in within our school system (football, FBLA, band, etc.):

What profession(s) or vocation(s) are you interested in: 

What subjects do you have difficulty in:

 


Student Essay

Why do you wish to attend the Douglas County Perfermance Learning Center? What do you hope to give and get out of this experience?

 



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