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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. Address
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    11. City/Zip
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    12. Home Phone Number
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    13. Student Cell Phone Number
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    14. Student Email address
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    15. Type of diploma desired:
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    16. Is the student currently employed
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    17. CURRENT COURSE SCHEDULE
    18. CURRENT TRANSCRIPT needed prior to finalizing new schedule.
    19. Current Course: 1
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    20. Current Course: 2
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    21. Current Course: 3
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    22. Current Course: 4
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    23. Current Course: 5
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    24. Current Course: 6
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    25. Intended length of enrollment and goal(s)
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    26. Coaches' Contact Information (i.e. Parent/Guardian, Probation Office, etc)
    27. 1. Name/Relationship
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    28. 1. Phone Number(s)
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    29. 1. Email Address
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    30. 2. Name/Relationship
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    31. 2. Phone Number(s)
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    32. 2. Email Address
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    33. 3. Name/Relationship
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    34. 3. Phone Number(s)
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    35. 3. Email Address
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    36. Please enter your digital signature by typing your first and last name in the field below:(*)
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    37. Click the Submit button to send this application

    38. Date Submitted:
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