WIMA & WIHI Discipline Request Form

REMINDER:

Please submit this form ONCE per year, per student!

Additional requests for the same student to the same school, will slow down the review process and may cause your student to NOT be able to participate in the lottery for the 25-26 school year.
Discipline Request Form

To be completed by families applying to WIMA and/or WIHI
Student Information:
Student Name:*

First NameLast Name
Student's Date of Birth:*

MonthDayYear
mm-dd-yyyy
Grade Student is applying for:*
This is the grade level the student is applying to at WIMA/WIHI
Parent/Guardian Information:
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Email:*

Confirmation Emailexample@example.com
Today's Date:*

MonthDayYear
Date
By signing below - I understand that my signature authorizes both parties to exchange disciplinary information only. If my student is accepted, I understand that another request will be sent to the school for my student's school records.
Parent/Guardian Signature:*

Clear
School Information

Currently Attending or Previously Attended
Name of School:*
School who has discipline records within the past 2yrs
Name of School Official to complete discipline Request Form:*

First NameLast Name
Email of School Official who will complete discipline form:*

Confirmation Emailexample@example.com
Canton Charter Academy - Please use email address: 39.sburoker@nhaschools.com for Sherri Buroker.

Clague Middle School Families - Please use email address: lindnerb@a2schools.org for Bethany Lindner.

Crescent Academy Families - please use email address: office@crescentacademy.org.

Honey Creek Families - Please use email address: shofbauer@honeycreekschool.org for Sue Hofbauer.

Lincoln Families:

Bishop Elementary Families - Please use email address: palmer@lincolnk12.org for Konnie Palmer

Brick Elementary Families - Please use email address: flucks@lincolnk12.org for Pam Flucks.

Child's Elementary Families - Please use email address: OrrisonM@lincolnk12.org for Meghann Orrison

Lincoln Middle School Families - Please use email address: callarinom@lincolnk12.org for Moneika Callarino.

Lincoln High School Families - please use email address: jacksonb@lincolnk12.org for Brianna Jackson.

MultiCultural Academy - please use email address: ssalman@macademyk8.com for Shayma Salman.

South Arbor Charter Academy Families - Please use email address: 19.dmiddlin@nhaschools.com for David Middlin.

YIES Families - Please use email address: acardona5@ycschools.us for Ally Cardona.

Ypsilanti Middle School Families - Please use email address: agossett3@ycschools.us for Andrea Gossett.

All others, please enter school official's email address twice to confirm their email address. This is what we will use to send them your student's discipline request form. Without this form completed, your student will not be considered for the lottery or enrollment. This form can be completed by a counselor, front office staff, dean of students, or an Admin.

Discipline Request Form

Student Information:

Parent/Guardian Information:

School Information

To Be Completed By Current School/School District