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    MSD Wabash County Distance Learning Application


    1. Student Name
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    2. Date of Birth
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    3. Grade Level
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    4. The student meets the following criteria for placement:



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    5. Additional barriers to education for the student (check any that apply):





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    6. Other barriers (from checkbox above)
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    7. Last School Attended
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    8. IEP or 504 Plan
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    9. Please list any medical concerns or medications
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    10. Please answer the following questions regarding the language spoken by the student:
    11. What is the native language of the STUDENT?(*)
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    12. What language(s) is spoken most often by the STUDENT?(*)
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    13. What language(s) is spoken by the STUDENT in the home?(*)
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    14. Address(*)
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    15. City/Zip(*)
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    16. Home Phone Number(*)
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    17. Student Cell Phone Number
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    18. Student Email address
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    19. Type of diploma desired:
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    20. Is the student currently employed
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    21. CURRENT COURSE SCHEDULE
    22. CURRENT TRANSCRIPT needed prior to finalizing new schedule.
    23. Current Course: 1
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    24. Current Course: 2
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    25. Current Course: 3
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    26. Current Course: 4
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    27. Current Course: 5
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    28. Current Course: 6
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    29. Intended length of enrollment and goal(s)
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    30. Coaches' Contact Information (i.e. Parent/Guardian, Probation Office, etc)
    31. 1. Name/Relationship
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    32. 1. Phone Number(s)
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    33. 1. Email Address
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    34. 2. Name/Relationship
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    35. 2. Phone Number(s)
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    36. 2. Email Address
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    37. 3. Name/Relationship
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    38. 3. Phone Number(s)
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    39. 3. Email Address
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    40. Please enter your digital signature by typing your first and last name in the field below:(*)
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    41. Click the Submit button to send this application

    42. Date Submitted:
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