Phone Number: Secondary Phone Number:
Email Address of Parent/Guardian:
Does the student have a sibling attending MDPS schools of choice program? yes no
Name of sibling:
Current grade of student 9 10 11 12
School District of Home Address: Name of Current School:
How did you hear about Madison District Public Schools? Direct MailFacebookRadioTVFrom a friendOther
Has the student been suspended from school within the last two school years? yes no
Has the student ever been expelled from school? yes no
Does this student have any special needs? yes no
Does the student have an I.E.P.? yes no
What is your child's Native Language?
Is the primary language in your child’s home a language other than English? yes no
If yes, what is the language?
Immigration date, if not born in the U.S.
I understand that by typing my name I am signing this application. I certify all of the information provided above to be true and correct. I acknowledge and accept the policies and stipulations of the Madison District Schools. I understand false or incomplete information will result in the removal of the applicant from Madison Schools programs.
Full name of parent or guardian: Date: