Application For Admission

Please print all information clearly and use codes listed on page 35.

OFFICE USE

Date Accepted _______________ Program ________________________________________

Student Name ______________________________________________________________________________________________________

LAST FIRST MIDDLE

School District of Residence ___________________________ School Last Attended/Presently Attending ____________________________

Student Address ___________________________________________________ City ____________________________________________

State ___________________________ Zip ____________ County ___________________________________________________________

Home Phone _________________ Soc. Sec. No. _________________ City of Birth ____________________ Birth Date __________________

Male Female Race Code _______________ E-Mail Address ______________________________________________

Parent/Guardian Information

Name ___________________________________________________ Name ___________________________________________________

Relationship ____________________________________________ Relationship ____________________________________________
Work Phone ____________________________________________ Work Phone _____________________________________________
Employer _______________________________________________ Employer _______________________________________________
Cell Phone ______________________________________________ Cell Phone _______________________________________________
E-Mail Address __________________________________________ E-Mail Address ___________________________________________

Home Address (if different from student) Home Address (if different from student)

______________________________________________________ _______________________________________________________

Next Year Grade Status 11 12

First Choice Career Program Code Program Name ________________________________________________________

Second Choice Career Program Code Program Name _________________________________________________________

PARENTS/GUARDIANS: Permission is granted for my son/daughter to apply for admission to MVCTC. I also, hereby, grant permission for any requested
student records, including the Ohio Graduation Test (OGT) scores, be released to MVCTC. The district will use the OGT scores to determine whether
the student needs to retake any parts of the OGT in order to fulfill Ohio state graduation requirements and to place the student in the appropriate
classes. The student information will only be disclosed to school officials and authorized representatives. This district will not re-disclose the
information. As a parent/guardian I recognize that it is my responsibility to devise a credit recovery plan with my son/daughter’s high school guidance
counselor for any credit deficiencies my child may have.

Parent/Student Comments____________________________________________________________________________________________
___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Signature of Applicant ____________________________________________________________ Date _____________________________

Signature of Guardian/Parent _______________________________________________________ Date _____________________________

Application For Admission

To be completed by partner school counselor.

Please attach student's transcript.

Is this student a resident of your school district? Yes No

If no, list status (example: Open Enrollment, Tuition, Court Placed, etc.)

___________________________________________________________________________________________________________

Attendance (List number of days absent) Grade 9 __________ Grade 10 __________ Grade 11 __________

Ohio Graduation Test Information: (List dates passed)

Writing _____________________________ Reading _____________________________ Math _______________________________

Social Studies _____________________________ Science _____________________________

Is English this student's second language? Yes No

If yes, what language is spoken in the household? ___________________________________________________________________

List deficiencies that cannot be met at MVCTC and how they will be satisfied

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Counselor Comments__________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Counselor Application Check-Off

Parent Signature Attendance OGT Scores Tech Prep Requirements Met

Transcript Course Request Form(s)

Counselor Signature ____________________________________________________ Date __________________________________________

The Miami Valley Career Technology Center is dedicated to providing equal admission opportunities, equal educational opportunities and equal employment
opportunities without regard to race, religion, color, national origin, ancestry, age, sex, sexual orientation, handicap, marital status, or veteran status.