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?
Security Measure