/ Western Technical College - Independence
Attn: Doris Mish
36084 Walnut Street
Independence, WI 54747

High School Registration Form

PLEASE PRINT CLEARLY AND PROVIDE THE FOLLOWING INFORMATION

Social Security # ______- ______- ______
Date of Birth: _____/______/_____ Phone:( ) ______- ______Male _____Female
Legal Last Name:______Full First Name:______Middle I:______
Mailing Address: ______
City: ______State: ______Zip: ______
Student’s E-mail Address:______
Legal resident of ______in the ______
County / City of / Village of / Town(ship) of
High School Currently Attending: ______/ Circle Highest Grade Completed: 9 10 11
Graduation Year: ______

Courses I wish to enroll in and are approved by my school board:

Course
Number / Course Title / Fall
Semester
(Starts September) / Spring
Semester
(Starts January) / # of Western credits

I understand that I will need to complete course prerequisite(s) or program admissions forms if applicable.

I certify the information on this form is true and complete to the best of my knowledge.

I understand that I must adhere to all Western policies and procedures as outlined in the Student Handbook

I authorize Western Technical College and my high school to share information with each other regarding my high school records and about my Western courses, attendance and grades.

I authorize Western Technical College’s instructors to exercise emergency medical care procedures in case of injury or sudden illness.

______Student’s Signature Date / ______Parent/Guardian’s Signature Date

Please also complete the information on the other side.

This information is collected to enhance programming efforts at Western and is voluntary.
Are you Hispanic or Latino (that is, a person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or origin, regardless of race? ___Yes ___No
American Indian / Asian / Black or African American / Native Hawaiian or other Pacific Islander / White
I am interested in the following Program(s): ______
School Board Approval
Please submit to High School Contact Person for completion.
Name of High School: ______Phone: ______
High School Contact Person: ______
Check one:
____Yes, this student is approved to enroll for both high school credit and post-secondary credit. We will reimburse Western for tuition, fees and materials.
____Yes, this student is approved to enroll, but postsecondary credit only. The student will be responsible for tuition, fees, and materials.
____No, this student does not have permission to enroll.
______
School Contact Person’s Signature Date

December 2017