Today's Date _______________________ Student ID# ________________________

Name________________________________________________________________

Mailing Address ________________________________________________________

Home
Phone __________________ Cell _______________Parent's Cell _______________

Birthdate _______________________ Social Security # _______________________

Grade Level ________________________ Ethnic Group_______________________

Do you drive a car to school? Yes_____ No_____ Make/Model ___________________

With whom
do you live? ____________________________ Relationship? ____________________

Parent's Name (Guardian) ________________________________________________

Parent's Place of Work _________________________ Work Phone _______________

Parent's Address (if different from yours) ___________________________________

Parent's email _________________________________________________________

PERSONAL INFORMATION

State any health problem you have that may affect your classroom performance.____________________________________________________________

Are you currently employed? Yes_____No_____ Where? _________________________

Boss's name: ___________________________ Phone ___________________________

What do you do? _________________________________________________________

When do you usually work? ________________________________________________


ESSAY: "WHY I WANT TO BE IN THE PTHS CREDIT RECOVERY/ACCELERATION PROGRAM"

Please list or describe the reasons why you wish to be placed in this program. Convince the placement committee that you are a good candidate for the program. Explain to the committee why you should be selected above everyone else who is applying. Describe your goals after graduation and why being in this program would help you achieve these goals.