Application for Full Time or Dual Enrollment (7-12)

Please complete the following information and submit. To expedite the enrollment process, fill in all the fields before you submit.

Student first name  
Student middle name  
Student last name  
Student last name extension if any (Jr., III)
  
Last name student goes by  
Grade  
For high school students, select the first year enrolled as a 9th grader  
Gender  

Date of birth

  
Ethnicity  
What is the primary language of the student?  
Student email address  
Student city/town of birth  
Student state of birth  
Student country of birth  
Birth Verification  
Emancipation  
Previous school attended  
Previous school type  
Previous school ID (if known)  
Previous state of school attendance  
Primary parent first name  
Primary parent last name  
Address  
City  
State  
Zip  
Dwelling  
(Area Code) Home phone  
Work phone  
Cell phone  
Parent email address
If you use a spam blocker, please add mdlp.org to your access/exception list		  
Parent employer  
Parent employer phone  
Alternate guardian name  
Alternate guardian contact information  
Will student be attending another district school at the same time?   Yes No
Type of internet connection   Dial-up Cable/DSL
Would you like to receive email progress reports each Monday?   Yes No
Are there any custody concerns?   Yes No ...If yes, please specify:
 

Please describe any existing IEPs or 504 services

  



If IEP, specify:

Does the student have a 504 plan? Yes No ...if Yes, please fax a copy to 480-472-7287

Computer that will be used  
Where did you hear about the Marana Distance Learning Program?  
What courses are you interested in taking?  

I would like a counselor to review course selection.
 

In order to receive free courses made available through state funding, all participants must agree to the following:

  1. Maintain a minimum of 5 hours per week per enrolled course.
  2. Submit and maintain weekly timesheets online.
  3. Participate in all state-mandated tests if applicable (AIMS). Check with your district for test dates and times. Test dates and times will be posted online at our main site and in the student main menu.

In submitting this registration form, I have read, understand and agree to maintain the minimum requirements for enrollment in the distance learning program. If I choose not to comply with the minimum requirements, I agree to either pay for each enrolled distance learning course in progress or otherwise completed during the current academic school year or forfeit all credit/s acquired during the academic school year. Failure to comply with the mandatory state testing requriements will result in a student's removal from the program and loss of credit.