MILLENNIUM HIGH SCHOOL APPLICATION

51 East Beverly Place, Tracy, CA 95376 209-290-0511

  ENERAL INFORMATION
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Which grade are you applying for: Date:

❑ 9 ❑ 10 ❑ 11 ❑ 12
How did you hear about us (Please mark one and name the source):
❑ Newspaper ❑ Television ❑ Internet ❑ Reference Name of Source:​____________________________________________________________

STUDENT’S INFORMATION
Last Name: First Name: Middle Initial: Gender: Date of Birth:
❑ Male ❑ Female / /
Street Address:

Apt / P. O. Box: City: State: Zip Code:

Home Phone No: Cell Phone No: Email Address:

( ) - ( ) -
FATHER / GUARDIAN’S INFORMATION
Father/Guardian’s Last Name: First Name: Middle Initial:

Address:

Suite / P. O. Box: City: State: Zip Code:

Work Phone No: Cell Phone No: Email Address:

( ) - ( ) -
MOTHER / GUARDIAN’S INFORMATION

Mother’s Last Name: First Name: Middle Initial:

Address: )

Suite / P. O. Box: City: State: Zip Code:

Work Phone No: Cell Phone No: Email Address:

( ) - ( ) -
Academic History
Sibling attending Tracy Name of Sibling Attending Tracy
Name of Current School:
Learning Center Learning Center

❑ Yes ❑ No
Street Address: City: Zip Code: Fluent in English?
❑ Yes ❑ No
State:

Does your Student have an IEP or

504 Plan?
Does your student receive special services? ❑ Yes ❑
❑ Yes ❑ No Has your student been expelled: ❑ Yes ❑ No
No