Pioneer Career & Technology Center Student Application

Student Application

All fields are required.

Student Information

Please provide your personal information.

Be sure to type your legal first name. For example: Michael not Mike

Don't forget to type your middle name.

Student First Name:

Student Middle Name:

Student Last Name:

Date of birth: (mm-dd-yyyy):

Student gender:

Male Female

Student Email address:

Primary phone number:
- -

Home address:

Student home address:

Apartment Number, etc.:

City:

State:

Zip Code:

Parent/Guardian Information

Contact Information

Please provide contact information for one Parent or Guardian who resides with the student.

Relationship to student:

Parent or Guardian First Name:

Parent or Guardian Last Name:

Alternate phone number:
- -

Parent or Guardian email address:

Pioneer Alumni?:
Yes No

Current School Information

Please provide information about the school you currently attend.

If your school is not listed, select '*All Other Schools' . If your school name does not appear in the second list, select '*Other School District' and type the name of your current school in the field.

Your current grade level:

09 10 11 12

Program Information

Select your first, second and third choice programs. You must select 3 different programs.

First Choice:

Second Choice:

Third Choice:

T-Shirt Size

Electronic Agreement

I understand that the enrollment process is not yet complete.
I will complete and return the required forms to my school counselor.

If your counselor does not receive all required forms,
you will not be considered for admission to
Pioneer Career & Technology Center.

I agree I do not agree

I certify that all statements I have made in this application are true, complete, and correct to the best of my knowledge; and that I am aware that any false statements, misrepresentations, or omissions of the facts will be sufficient cause for dismissal.
I understand there are school fees required for this program.

I acknowledge that I am forwarding this application to Pioneer electronically and that I have agreed to conduct this transaction electronically.

I agree I do not agree

EQUAL OPPORTUNITY EMPLOYER

In accordance with Title VI, Title IX and Section 504 (to include Discrimination and Harassment) the Pioneer Career and Technology Center is an equal opportunity institution. Educational activities, employment practices, programs and services are offered without regard to race, color, national origin, sex, age, disability, military status or socio-economic status. Mary Lee Barr, Title VI Coordinator Civil Rights; or Chris Kowalski, Section 504, Disability and Title IX, Sexual Harassment Coordinator, can be reached at
419-347-7744.

Submit Date: 06/23/2018 10:53 PM