Student MES Application

Student MES Application

Use this application to request enrollment in the MES program. Completion of this form constitutes an application for placement; it does not guarantee acceptance. The information provided will be used to determine eligibility, placement priority, and any applicable fees. By submitting this form the Applicant or Parent/Guardian certifies that the information provided is true, complete, and accurate to the best of their knowledge.

Student Information

Date of Birth:    Student ID (if issued):    Grade/Program Applying For:

Primary Language Spoken at Home:    Current School or Program:

Parent/Guardian Information

Relationship to Student:    Primary Phone:    Alternate Phone:

Emergency & Medical Information

Emergency Contact Phone:    Alternate Phone:

Physician Name and Phone:    Insurance Provider / Policy #:

Program Selection & Enrollment Preferences

Select Program Type (check all that apply):

Full Day    Half Day    After-School    Summer Program

Academic & Special Services

Current Grade:    Current GPA (if applicable):

Is the student currently receiving special education services or accommodations?    Yes    No

Financial Information

Tuition Amount (annual): $    Payment Option:    Full Payment    Monthly Installments

Scholarship or Financial Assistance Requested:    Yes    No

Eligibility Checklist

Student resides within program service area
Student meets age requirements for requested program
Immunizations are current and records will be provided
Academic and disciplinary records are accurate to my knowledge

Consent and Authorizations

Emergency Medical Treatment Authorization: In the event of a medical emergency involving the student named herein, I authorize program staff to seek and consent to emergency medical treatment, including transportation to a medical facility, and I agree to assume financial responsibility for such treatment.

I hereby authorize emergency medical treatment as described above

Photo/Media Release: Program activities may be photographed or recorded for educational or promotional purposes. Indicate your preference below.

I consent to the use of photos/video of the student for program purposes    I do not consent

Transportation Authorization: I authorize the student to travel on program-approved transportation for program activities.

Transportation authorized    Transportation not authorized

Acknowledgment, Certification, and Program Policies

By signing below, I certify under penalty of perjury that the information on this application is true and complete. I understand that false statements or omission of material facts may result in denial of enrollment or revocation of placement. I authorize the release of school records, health records, and other information necessary to verify information provided in this application and to determine eligibility and placement.

I acknowledge that placement is subject to program capacity, priority rules, and verification of eligibility. I accept responsibility for any tuition, fees, or costs assessed in accordance with program policy. I understand that fees may be nonrefundable once services have commenced and that the program reserves the right to suspend or terminate enrollment for failure to comply with program policies, nonpayment, or conduct that endangers the health or safety of others.

Optional Information

Sign Now