SHARE PCS ADMISSIONS APPLICATION

Admission Year*

Is the applicant a former PCS student?
YesNo

Student's First Name*

Middle

Last Name*

Suffix

Preferred Name

Gender:
MaleFemale

Address*

City, State, Zip*

Date of Birth*

Age*

Place of Birth*

Race*

Current School Program*

Current Grade*

Has student ever been dismissed or disciplined at any school?
YesNo

If yes, please explain.

Does student currently have an IEP or a 504 plan?
YesNo

If yes, please upload copies of all written evaluation reports with this application.

Accepted file types - .doc, .pdf, .txt, .jpg

Have you previously taken an on-line course:
YesNo

If, yes, please list the school you partnered:

Course(s) you are interested in taking:*

Do you have reliable internet connection to use for class work and virtual meetings:*
YesNo

Father/Guardian
Typing name here acts as signature

Date

Mother/Guardian
Typing name here acts as signature

Date

Father/Guardian Name (Title, First Name, Middle Initial, Last Name)

Address (if different from student)

Street Address, City, State, Zip

Home Phone

Cell Phone

Busness Phone

Employer

Occupation

Mother/Guardian Name (Title, First Name, Middle Initial, Last Name)

Address (if different from student)

Street Address, City, State, Zip

Home Phone

Cell Phone

Busness Phone

Employer

Occupation

Name (Title, First Name, Middle Initial, Last Name

Address

Street Address, City, State, Zip

Home Phone

Cell Phone

Business Phone

We have read and agree to support the PCS Statement of Faith. By typing your name in the fields below you acknowledge this statement to be true.

Parent/Guardian Information

Person Responsible For Bill (If different from parent or guardian listed above)