STUDENT APPLICATION FORM
Name ____________________________________ WVEIS Number_____________ High School _____________
Address_______________________________________ Email_________________________________________
City___________________________________ State__________ Zip ___________ Phone # _________________
Best number to reach parent/guardian_________________________ Alternate Number ___________________
Programs Offered
(Modify List to Match Your School)
Automotive Technology
Business Information Technology
Carpentry
Careers in Ed/Child Development
Computer Aided Drafting
Welding Technology
Computer Technology
Electrical Technology
Foods Management (Pro Start)
Forestry
Health Occupations
Agribusiness Systems
Leadership Ed (JROTC)
Masonry
Parks & Recreation
Pharmacy Technician
Pre-Engineering (PLTW)
Transportation Technology
INDICATE IN WHICH PROGRAMS YOU WISH TO ENROLL (Please pick your top 3 choices)
What is your reason for wanting to enroll in this program? (Note: You will only be selected for 1 program)
Choice 1: _____________________________ Choice 2:____________________________________________
Choice 3: __________________________________________________________________________________
What are your plans after high school? ___________________________________________________________
References:
-
Name:_____________________________________ Phone: ___________________________________
(Someone not related to you)
-
Name:_____________________________________ Phone: ___________________________________
(Someone not related to you)
Student Signature:__________________________________________ Date: ____________________________
Non-Discrimination: The (Name of Recipient) does not discriminate on the basis of race, color, national origin, sex, disability, or age in its
programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies:
Name and/or Title:
Address:
Telephone No:
-------------------------------------------------------- Do Not Write Below This Line ------------------------------------------------------(For School Use Only)
Student GPA __________
Days Absent in current year _________
Number of Failed Classes _________