STUDENT INTEREST FORM

Completion of this form represents your interest in enrollment. It is not a guarantee.

Date ___/___/___

Student Name

Female

Parent/Guardian

__________ Phone

Male

________________
Zip

Address

Parent Email Address __________________________________________________________

Date of Birth
Current school

Age

Current Grade

Credits Earned*

______Attending? Y N Previous School _______________________

*Please provide a copy of your current High School Transcript

Student Needs (check all that apply)

Special Ed/IEP (Please provide current copy)
Section 504 (Please provide current copy)
Expulsion - Date of Hearing:
Reason for referral (check all that apply)
Academic difficulties
Attendance difficulties
Depression
Drug and alcohol issues
Past abuse history
ADHD/ADD
School anxiety

Pregnant/Parenting
ESL Home Language:

Fighting with peers

Struggling with authority
Juvenile Justice Involvement
Bullying
Other: _________________

Do you know anyone currently attending Mt. Scott? Name:_________________________________

Tell us why you think Mt. Scott would be a good fit for you:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
OFFICE USE ONLY

Wait List
Letter Sent? Y / N
Referral to Direction Services? Y / N
Interview
Date
Accepted
Start date

PPS ID:

AcP? Y / N

Date
Date
Group

Advisor