Please Print. Illegible Handwriting May Result in Delayed Enrollment

Please print. Illegible handwriting may result in delayed enrollment.

Part 1: Student Information

StudentLEGAL Name ______Graduation Year______

FIRST MI LAST

Birth Date___/___/___ Gender: ______

Student Email: ______Student Cell Number: ______

Student Ethnicity:
____American Indian (Tribe) ______
____Asian
____Black
____ White
____Pacific Islander
____Hispanic / Student Lives With:
__Father
__ Mother
__Both
__Guardian ______
__On Own__ Address: ______

Student’s Birth Place (City, State or Country) ______

Student’s Primary Language ______Student’s Home Language ______

Is there anything you would like us to know about you, your learning style, or any other important information?

______

Part 2: Parent/Guardian and Emergency Information

Contact 1:
Parent___ Guardian___
______
Last First
Relationship to student: ______Address ______
City______Zip Code______
Home Phone: ______Cell: ______
Email ______/ Contact 2:
Parent___ Guardian___
______
Last First
Relationship to student: ______Address ______
City______Zip Code______
Home Phone: ______Cell: ______
Email ______

Emergency Contact Not living with Student

Name ______Relationship______Phone ______

I authorize the Northwest Career & Technical Academy to: Have access to any and all of my student’s school records; to use my student’s Social Security number for the purposes of processing and identifying records routinely associated in all reports at local, state levels, and post-graduation information; to obtain my student’s photo and/or statements as they relate to the mission of the Academy, and/or to aid in the success and promotion of career & technical education. The signature of students over the age of 18 living independently verifies agreement. I also understand that if my student participates in an off-campus program, location, or clinical, I will be required to provide transportation.

Parent/Guardian Signature______Date______

Part 3: Academy Program Selection

Unless noted in the Session 3 offerings all classes run Monday through Friday. The Academy follows the Mount Vernon School District Calendar for breaks and most half days.

Mount Vernon Main Campus 2205 West Campus Place
Mount Vernon, WA 98273
Academy Program / Session 1
8:00 – 10:30 / Session 2
11:25 – 1:55 / Session 3
Mon-Thurs
3-6:15
Veterinary Assisting / FULL / FULL / FULL
Money & Business / Not Offered
Criminal Justice & Public Safety / Not Offered
Culinary Arts
Dental Technology / FULL /  NEW!!
DigiPen Video Game Programming / FULL
Healthcare Careers / Call first
Anacortes Campus 1606 R Avenue Anacortes, WA 98221
Academy Program / Session 1
8:00 – 10:30 / Session 2
11:25 – 1:55
Aerospace Manufacturing
Marine Technology / FULL
/ Whatcom County Campus @ Meridian High School
194 West Laurel RoadBellingham WA 98226
Academy Program / Session 1
8:00 – 10:30
Welding / FULL
Sustainable Engineering
Construction / FULL

Would you be interested in a program if it was offered at an alternative time? _____ Which Program? ______

Would you be interested in an afternoon (3-5:30) session if it was offered? ______Which Program? ______

Are there any programs you would like to see offered at the Academy? ______

I understand that completing this application does NOT guarantee admittance to the Northwest Career & Technical Academy. I also understand that if I participate in an off campus program, location, or clinical, I will be required to provide my own transportation.

Student Signature______Date______

Part 4: Completed by sending high school counselor Previously Attended the Academy: No___ Yes ___ Proposed Start Date: ______

Sending High School______2014-15 Grade Level ______Current GPA______Student SSID#______

IEP: No______Yes______Copy Attached: ______504 Plan: No______Yes______Copy Attached: ______

Medical Alert: No___ Yes___ Explain: ______

Is the student required by court action to attend school? Yes___ No___ Becca Status ______

If yes, does he/she have a PO? Yes___ No___ Name of PO ______Phone ______

High School Administrator assigned to student: ______

Are there any attendance concerns? ______

Any other information or concerns we should be aware of with this student? ______

Counselor Name: PRINT ______Counselor Signature:______Date: ______

JAN 2015