MIDLANDS MIDDLE COLLEGE
A SOUTH CAROLINA PUBLIC CHARTER HIGH SCHOOL
PHYSICAL ADDRESS: MIDLANDS TECHNICAL COLLEGE, AIRPORT CAMPUS,
1260 LEXINGTON DRIVE, WEST COLUMBIA, SC 29170
MAILING ADDRESS: PO BOX 2408, COLUMBIA, SC 29202
EMAIL: INFO@MIDLANDSMIDDLECOLLEGE.COM
2015-2016 STUDENT ENROLLMENT FORM
DATE_______________
STUDENT INFORMATION
__________________ __________________ __________________ ____________ ____________
Last Name
First Name
Middle Name
Gender
Birth Date
__________________ __________________
Country of Birth
Social Security #
Ethnic Code:
American Indian or Alaska Native
Asian
Black or African American
Grade Level 2015-2016: 11
12
Native Hawaiian or Other Pacific Islander
White
Current School and Address
Home-based High School (High School assigned to your neighborhood)
English Proficiency:
Unknown
Special programs/services received at previous school:
Migrant:
Yes
Foster Home:
Lives in Foster Home
LEP
IEP
ESOL
504
English
Other___________
No
Student Lives with ____________________________
Does Not Live in Foster Home
Relationship ____________________________
Does student have any physical problems that may affect school attendance? _____________________
FATHER’S INFORMATION
_________________
Father’s Last Name
__________________ _________________
Father’s First Name
Home Phone #
__________________________
Email Address
_________________________________________________________ __________________________
Employer and Occupation
Work Number & Ext. Cell #
_________________________________________________________
Residence Address (street number, street name, street type, city, state, and zip code)
__________________________
County
Mailing Address (street number, street name, street type, city, state and zip code)
Email address _________________________________________________________________________
Educational Level:
Primary-Grades 1-8
Bachelors
High – Grades 9-12
Masters
No HS Diploma (GED)
Ph.D or M.D.
MOTHER’S INFORMATION
_________________
Mother’s Last Name
__________________ _________________
Mother’s First Name Home Phone #
__________________________
Email Address
_________________________________________________________ __________________________
Employer and Occupation
Work Number & Ext. Cell #
_________________________________________________________
Residence Address (street number, street name, street type, city, state, and zip code)
__________________________
County
Mailing Address (street number, street name, street type, city, state and zip code)
Email address _________________________________________________________________________
Educational Level:
Primary-Grades 1-8
Bachelors
High – Grades 9-12
Masters
No HS Diploma (GED)
Ph.D or M.D.
GUARDIAN’S INFORMATION
____________________________ __________________________
____________________________
Legal Guardian/Step-Parent’s Last Name
Home Telephone #
Legal Guardian/Step-Parent First Name
___________________________________________________________________
Employer and Occupation
__________________________________
Work Number & Ext. Cell #
_________________________________________________________
Residence Address (street number, street name, street type, city, state, and zip code)
__________________________
County
Mailing Address (street number, street name, street type, city, state and zip code)
Email address _______________________________________________________________________
Proof of Guardianship:
Court Order
Affidavit
SIBLING INFORMATION
Sibling Name
School Attending
Grade
EMERGENCY INFORMATION
Medical Alert 1 (i.e. Allergies, Asthma, Medical Conditions, etc.)
Medical Alert 2 (Medication)
Medical Alert 3 (Special Accommodations)
Emergency Contact 1 (Name, Telephone Number & Extension)
Relationship to Student:
Mother
Father
Step Mother
Step Father
Foster Mother
Foster Father
Guardian
Neighbor
Brother
Sister
Grandmother
Grandfather
Spouse
Parole Officer
Brother
Sister
Grandmother
Grandfather
Spouse
Parole Officer
Emergency Contact 2 (Name, Telephone Number & Extension)
Relationship to Student:
Mother
Father
Step Mother
Step Father
Foster Mother
Foster Father
Guardian
Neighbor
Physician Name & Telephone Number
Hospital Preference
Other Important Information: ____________________________________________________________
The following items should be returned at this time:
1.
2.
3.
4.
A copy of social security card
Documentation of Residency (i.e. copy of phone bill or electric bill)
A copy of immunization records
Enrollment packet
Note: Parents are responsible for getting all requested information to Midlands Middle College, A
South Carolina Public Charter School. Completed forms must be delivered, mailed or faxed and be
received by Midlands Middle College by Thursday, May 15, 2014. The fax number is 803-822-7039.
_______________________________ _____________________________
Parent/Legal Guardian Signature
Student’s Signature
___________________
Date
At a later time, the following information will be requested as part of admissions and enrollment:
Copy of current transcript
Copy of discipline record
Copy of attendance record
Copy of current 504 or IEP (if applicable)
Midlands Middle College does not discriminate on the basis of race, color, national origin, sex, disability,
age, religion, or immigrant status in its programs and activities and provides equal access to the Boy Scouts
and other designated youth groups. For questions pertaining to Section 504 and Title IX, contact the
Midlands Middle College at 1260 Lexington Drive, West Columbia, SC 29170, 803-822-7043.