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Clackamas Middle College Application for Enrollment

Please complete the application below. Required fields marked with an asterisk *

How did you find out about Clackamas Middle College?*

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Date:*

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Student Contact Information

Student First Name*

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Student Middle Initial*

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Student Last Name*

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Student Date of Birth*

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What grade are you in at your current school?*

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8th

9th

10th

11th

12th

Last/Current School Attended*

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Last/Current District Attended*

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Student Home Street Address*

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Student Home City*

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Student Home Zip/Postal*

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Student Phone*

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Student Email *

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Does the prospective student have (ever had), an IEP, 504 Plan, or ELL Services?*

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Yes

Explain

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1st Parent/Guardian/Caregiver Information

1st Parent/Guardian/Caregiver Name*

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1st Parent/Guardian/Caregiver Phone*

Number Required

1st Parent/Guardian/Caregiver Email*

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1st Parent/Guardian/Caregiver Street Address*

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1st Parent/Guardian/Caregiver City*

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1st Parent/Guardian/Caregiver Zip/Postal*

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2nd Parent/Guardian/Caregiver Information

2nd Parent/Guardian/Caretaker (If Applicable) Name*

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2nd Parent/Guardian/Caretaker (If Applicable) Phone*

Number Required

2nd Parent/Guardian/Caretaker (If Applicable) Email *

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2nd Parent/Guardian/Caretaker (If Applicable) Street Address*

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2nd Parent/Guardian/Caretaker (If Applicable) City*

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2nd Parent/Guardian/Caretaker (If Applicable) Zip/Postal*

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Confirmation Email

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