About
Entering grade
9th
10th
11th
12th
Name
Name
Name
Name
Name
Name
Name
Email
Phone
Previous School Services
Does the student have a disability (learning, medical or physical?)
Yes
No
Has the student ever had a serious injury?
Yes
No
Does the student currently have a 504 plan?
Yes
No
Does the student currently have an IEP (individualized education plan) for Special Education Services?
Yes
No
Please provide a copy of the student's IEP to the school office.)
Yes
No
Why
Has the student been tested and determined to be gifted?
Yes
No
Has the student received English as a Second Language (ESL) services?
Yes
No
What services or additional support was arranged?
Previous School Attended
What is the name of the school that student attended prior to TMP?
School City:
State:
Has the student ever been suspended for 10 or more consecutive days?
Yes
No
(If YES, please provide dates and reason)
Has the student ever been expelled from school?
Yes
No
(If Yes, please provide dates and reason)
Information Disclosure
TMP may be requested to provide contact information (name, address and phone number) of our high school juniors and seniors to military recruiters, colleges and other groups.
You are not required to participate in this program.
I Authorize the MASTERS Program to disclose my child's contact information to ANY organization
Confirm
DO NOT DISCLOSE my child's contact information to ANY organization
Confirm
DO NOT DISCLOSE my child's contact information to the organizations checked below:
Confirm
US Military (Army, Navy, Air Force, Marines, etc)
Colleges and other educational institutions
Prospective employers
This information will stay on file in the School Office for the duration of time your student is enrolled at TMP. If you wish to make changes to the form, it is your responsibility to contact the TMP Office. I attest that all information contained in this form is true and correct to the best of my knowledge.
Parent/Guardian's Name:
Parent/Guardian's Signature:
Date
Parent/Guardian/Family Information
Parent/Guardian 1:
Is this person allowed to pick up the student from school?
Yes
No
Relationship to Student:
First Name:
Middle Initial:
Last Name:
Home Phone:
Mobile Phone:
Email Address:
Place of Employment:
Work Phone:
Does the above person live in the same household as the student?
Yes
No
If no, please provide the following:
Address:
City:
State:
ZIP:
Home Phone:
Parent/Guardian 2:
Is this person allowed to pick up the student from school?
Yes
No
Relationship to Student:
First Name:
Middle Initial:
Last Name:
Home Phone:
Mobile Phone:
Email Address:
Place of Employment:
Work Phone:
Does the above person live in the same household as the student?
Yes
No
If no, please provide the following:
Address:
City:
State:
ZIP:
Home Phone:
Are you or is your parent/guardian a member of the National Guard, Military Reserve or on Active Duty in the United States Military?
Please indicate by choosing one of the following:
Active Duty
National Guard
Reserve
Not in any branch of the United States Military
Are you (the student) a first generation college student. A first-generation college student is defined as a student whose parent(s)/legal guardian(s) have not completed a bachelor's degree. This means that you are the first in your family to attend a four-year college/university to attain a bachelor's degree. Being first-generation is a very proud accomplishment.
Yes
No
Are you, your parent/guardian, or spouse a migratory agricultural worker (includes dairy and fishers), who in the last 3 years has moved from one school district to another in order to obtain temporary or seasonal employment in the agricultural, dairy, or fishing industry?
Yes
No
Emergency Contact Information
#1: Do NOT list the parent/guardian above)
First Name:
Last Name:
Emergency Phone:
This is (check one only)
Mobile
Work
Home
#2: Do NOT list the parent/guardian above)
First Name:
Last Name:
Emergency Phone:
This is (check one only)
Mobile
Work
Home
In the event of an emergency, I hereby give permission to TMP and its designee to transport and/or seek medical attention for my child.
Family Physician:
Phone:
Preferred Hospital:
All information contained on this card is true and correct to the best of my knowledge. It is the parent/guardian’s responsibility to notify the school office if any of this information changes.
Parent/Guardian Signature
Date
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