Common use of PLEASE PRINT CLEARLY Clause in Contracts

PLEASE PRINT CLEARLY. Part I: To be filled out by the applicant along with the parent(s)/guardian(s) Student Name: Date of Birth: Home Address: City: State/Zip: Phone Number: SS# Do you currently have an IEP, 504 plan? YES or NO (Circle one) If you have an IEP, who is your case manager? Please provide the name(s) and phone contact(s) of your parent(s)/guardian(s) (unless you are live on your own) Parent/Guardian Name: Home Phone #: Cell or Work phone: Name of Emergency Contact: Home Phone #: Cell or Work Phone: Does the student have any medical conditions that we need to be aware of? YES or NO If yes, please list (be sure to turn in the proper medical forms to the CHS nurse as well): What is the student’s plan for transportation to and from the program? Part II: To be filled out completely by the student / applicant Please answer each question completely and LEGIBLY! Why do you feel you are a good candidate for the Missouri Option Program? What difficulties have you experienced in school in the past that has stopped you from succeeding? Why do want to enroll in the Missouri Option Program as opposed to getting your HiSET? Do you plan to go to college? What do you feel are your strengths and weaknesses? Part III: To be completed by the Missouri Option Program Coordinator[s] prior to student placement Name of student: Grade: _ Date of Birth: Age: Current Total Credits: Cohort Kindergarten: Is the student a 4th year senior? If not, what cohort graduation year? Has the student ever been retained? If so, how many years and when? Student’s plan for achieving the work requirement: Please answer yes or no to the following:

PLEASE PRINT CLEARLY. Part I: To be filled out by the applicant along with the parent(s)/guardian(s) Student Name: Date of Birth: Home Address: City: State/Zip: Phone Number: SS# Do you currently have an IEP, 504 plan? YES or NO (Circle one) If you have an IEP, who is your case manager? Please provide the name(s) and phone contact(s) of your parent(s)/guardian(s) (unless you are live on your own) Parent/Guardian Name: Home Phone #: Cell or Work phone: Name of Emergency Contact: Home Phone #: Cell or Work Phone: Does the student have any medical conditions that we need to be aware of? YES or NO If yes, please list (be sure to turn in the proper medical forms to the CHS nurse as well): What is the student’s plan for transportation to and from the program? Part II: To be filled out completely by the student / applicant Please answer each question completely and LEGIBLY! Why do you feel you are a good candidate for the Missouri Option Program? What difficulties have you experienced in school in the past that has stopped you from succeeding? Why do want to enroll in the Missouri Option Program as opposed to getting your HiSETProgram? Do you plan to go to college? What do you feel are your strengths and weaknesseswhat do you need to improve? Part III: To be completed by the Missouri Option Program Coordinator[s] prior to student placement Name of student: Grade: _ Date of Birth: Age: Current Total Credits: Cohort Kindergarten: Is the student a 4th year senior? If not, what cohort graduation year? Has the student ever been retained? If so, how many years and when? Student’s plan for achieving the work requirement: Please answer yes or no to the following: