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Testimonials

I love WMAES. This school is tremendous and I couldn't imagine sending my son anywhere else.

Jennifer Dietrich

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2010-2011 Registration Form

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Student Information

Last Name:

First Name:

Middle Name:

Address:

City:

Zip Code:

Home Phone:

Social Security #:

Email:

Date of Birth:

Grade:

Gender:

Legal Guardian 1

Last Name:

First Name:

Middle Name:

Address:

City:

Zip Code:

Relationship:

Home Phone:

Cell Phone:

Employer:

Work Hours:

Work Phone:

Alternate Phone:

Alternate Phone Type:

Email:

Legal Guardian 2

Last Name:

First Name:

Middle Name:

Address:

City:

Zip Code:

Relationship:

Home Phone:

Cell Phone:

Employer:

Work Hours:

Work Phone:

Alternate Phone:

Alternate Phone Type:

Email:

Emergency Contact

Last Name:

First Name:

Middle Name:

Address:

City:

Zip Code:

Relationship:

Home Phone:

Cell Phone:

Employer:

Work Hours:

Work Phone:

Alternate Phone:

Alternate Phone Type:

Email:

How did you hear about WMAES?:

If referred, by whom?:

School Last Attended

School Last Attended:

Address:

Did your child have special education services provided at a previous school?
Yes No

If yes, what services?

Please indicate if this student has been:

Suspended

District:

Reason:

Date:

Expelled

District:

Reason:

Date:

Medical Information

Family Doctor:

Phone:

Place of Birth:

Special Medical Needs:

Dates of Immunizations:

Immunization	1st dose	2nd	3rd	4th	5th	6th
DPT/Td/DT/DtaP
OPV/IPV
MMR
HEP-B
Varicella

Has your child had the following:

Chicken Pox Rubella Measles Mumps

Vision and Hearing

Vision: Passed Failed Hearing: Passed Failed

Waiver Reasons

Medical Religions Other Comments

Other Information

Ethnic Code - include all that apply (rank 1-6)

American Indian

Hispanic

Asian

White

African American

Pacific Islander

Language spoken at home:

Multiple Birth

Do you have a computer? Yes No
Do you have Internet access? Yes No
Born in USA? Yes No

Date moved to USA:

Did you move for work? Yes No

Description of Work

Country of Origin:

Primary Language:

Interpreter for Parents? Yes No

Years outside USA:

Years inside USA:

Family Information

Please list other children living at this address

Name:

Birth Date:

Name:

Birth Date:

Name:

Birth Date:

Name:

Birth Date:

Once you have completed all required fields and agree to the terms (by checking the box the box below) your application is now ready to submit! Please click "Submit Application" button. A confirmation email will be sent to the email address listed under legal guardian one. By checking this box, I certify that all information provided in this application and in all accompanying forms is true, accurate, and complete.

Testimonials

2010-2011 Registration Form

Please indicate if this student has been:

Suspended

Expelled

Dates of Immunizations:

Has your child had the following:

Vision and Hearing

Waiver Reasons

Ethnic Code - include all that apply (rank 1-6)

Please list other children living at this address

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