The MASTERS Program

Student Enrollment Form SY 2023-2024

Please Fill Out All Requested Information. This online form will not work on Safari, please use another browser

Student is entering grade: 9th10th11th12th

First Name: Middle: Last:

Date of Birth:

Physical Address:

City: State: Zip:

Mailing Address:

City: State: Zip:

Student Email Address: Student Cell Phone:

Students Gender: FemaleMale Student's Current Age:

Student's Primary Race/Ethnicity: (Check One Only)

Middle EasternAsianBlack/African AmericanWhite/CaucasianHispanic/Latinx originNative AmericanPacific Islander

Other:

American Indian or Alaskan Native (please specify): —Please choose an option—IsletaNavajoSandiaAcomaCochitiMescaleroApacheNambePicurusPojoaqueSan FelipeJemezLagunaSan IldenfonsoJicarillaApacheSan JuanSanta AnaSanta ClaraSanto DomingoTaosTesuqueZiaZuni

Other:

If student is American Indian or Alaskan Native: (Please provide a copy of your CIB and FF506 to the school office)

Does the student have a CIB? YesNo Does the student have a FF506? YesNo

Country of Birth: Is the student a single parent? YesNo

Has the student been enrolled for the last 3 consecutive years in US Schools? YesNo
Is there a computer at home? (e.g. desktop/laptop) YesNo
Is there Internet access at home? YesNo

How many times has the student's family moved in the past 12 months?
Where do you and your family currently live? Select only 1 (one).

Live in my own home (rent or own) with immediate family (parents, spouse/partner, children).Temporarily with another familyWith an adult that is not a parent or legal guardianRent in a temporary space (motel, hotel, trailer park or campground or shelter)Other

Previous School Services

Does the student have a disability (learning, medical or physical?) YesNo
Has the student ever had a serious injury? YesNo
Does the student currently have a 504 plan? YesNo

Does the student currently have an IEP (individualized education plan) for Special Education Services? YesNo
Please provide a copy of the student's IEP to the school office.)

Did the student previously have an IEP? If so, when

why
Has the student been tested and determined to be gifted? YesNo

Has the student received English as a Second Language (ESL) services? YesNo
If yes, which dates?

At your previous school(s) were you referred to the Student Assistance Team (SAT) for service/support to assist you in academic and/or social success?
If so, when did this occur? Date

What services or additional support was arranged?

Previous School Attended

What is the name of the school that student attended prior to TMP?
School Name: School City: State:

The school the student attended previously can be categorized as: (Check one only) PublicPrivateLocated outside the countryInstitution (example: correctional facility, treatment center, etc)Charter SchoolHome School
Has the student ever been suspended for 10 or more consecutive days? YesNo
(if YES, please provide dates and reason)
Has the student ever been expelled from school? YesNo If Yes, please provide dates and reason

Information Disclosure

TMP may be requested to provide contact information (name, address and phone number) of our high school juniors and seniors to military recruiters, colleges and other groups. You are not required to participate in this program.

I Authorize the MASTERS Program to disclose my child's contact information to ANY organizationDO NOT DISCLOSE my child's contact information to ANY organizationDO NOT DISCLOSE my child's contact information to the organizations checked below:
US Military (Army, Navy, Air Force, Marines, etc)Colleges and other educational institutionsProspective employers

This information will stay on file in the School Office for the duration of time your student is enrolled at TMP. If you wish to make changes to the form, it is your responsibility to contact the TMP Office.
I attest that all information contained in this form is true and correct to the best of my knowledge.

Parent/Guardian's Name:
Parent/Guardian's Signature: (by typing your name into this box, you are signing this document. Date:

Parent/Guardian/Family Information

Parent/Guardian 1:

Is this person allowed to pick up the student from school? YesNo Relationship to Student:

First Name: Middle Initial: Last Name:

Home Phone: Cell Phone: Email Address:

Place of Employment: Work Phone:

Does the above person live in the same household as the student? YesNoIf no, please provide the following:

Address: City: State: Zip:

Home Phone:

Parent/Guardian 2:

Is this person allowed to pick up the student from school? YesNo Relationship to Student:

First Name: Middle Initial: Last Name:

Home Phone: Cell Phone: Email Address:

Place of Employment: Work Phone:

Does the above person live in the same household as the student? YesNoIf no, please provide the following:

Address: City: State: Zip:

Home Phone:

Are you or is your parent/guardian a member of the National Guard, Military Reserve or on Active Duty in the United States Military?

Please indicate by choosing one of the following: —Please choose an option—Active DutyNational GuardReserveNot in any branch of the United States Military

Are you (the student) a first generation college student. A first-generation college student is defined as a student whose parent(s)/legal guardian(s) have not completed a bachelor's degree. This means that you are the first in your family to attend a four-year college/university to attain a bachelor's degree. Being first-generation is a very proud accomplishment. YesNo

Are you, your parent/guardian, or spouse a migratory agricultural worker (includes dairy and fishers), who in the last 3 years has moved from one school district to another in order to obtain temporary or seasonal employment in the agricultural, dairy, or fishing industry? YesNo

Emergency Contact Information

#1: Do NOT list the parent/guardian above)

First Name: Last Name:

Emergency Phone Number: This is (check one only) CellWorkHome

#2: Do NOT list the parent/guardian above)

First Name: Last Name:

Emergency Phone Number: This is (check one only) CellWorkHome

In the event of an emergency, I hereby give permission to TMP and its designee to transport and/or seek medical attention for my child.

Family Physician: Phone: Preferred Hospital

All information contained on this card is true and correct to the best of my knowledge. It is the parent/guardian’s responsibility to notify the school office if any of this information changes.

Parent/Guardian Signature (By typing your name, you are electronically signing this document) Date:

Please type the characters: (case sensitive)