HAZEL PARK ALTERNATIVE HIGH SCHOOL REGISTRATION FORM

Request Type*

Current/Previous MCA StudentNew Student
Semester*

Summer '25/26Fall '25/26Undecided
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Sex*
Current School - Resident School District*
Previously Attended Hazel Park Schools*

YesNo
Current Grade*
Last School Attended*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Select One*

HomeMobileWork
Ethnic Origin*
Hispanic*

YesNo
Primary Language*
Home Language*
Language spoken at home
Special Education Services*

YesNo
If Yes, Date of IEP

MonthDayYear
If unknown, leave blank
REASON FOR ALTERNATIVE HIGH SCHOOL REGISTRATION

Please select "yes" for the reason(s) you want to register/re-register for alternative high school. Please note that we can only register students for one of the following reasons.
Has Student Been Expelled*

YesNo
If yes, explain*
Court Referred*

YesNo
Teen Pregnancy*

YesNo
At Risk of Dropping Out*

YesNo
Warning: One of the above reasons must be selected to be considered for acceptance/continuation into MCA's progam. You have selected "No" for each of the above reasons. If this was made in error, please make necessary changes before proceeding.
Additional Information for Applying for Alternative Educational Placement
As the parent(s)/legal guardian making application for Alternative Education under Sections 6(4) or 6(6) of the State School Aid Act (MCL 388.1606(4) or MCL 388.1606(6), my/our signature(s) on this application signifies my/our understanding and agreement to Alternative Education and guidelines and to all rules and regulations of student handbooks. It is also understood that if Hazel Park Schools finds any information that is incorrect or falsified on this application, including affirmation of prior discipline records, this would immediately terminate enrollment of the student on this form. My/our signature(s) holds harmless the Hazel Park School District, their employees, and Board of Education members for any decisions made relative to the Alternative Education language and guidelines. It also grants Hazel Park School District permission to contact current and previous districts to obtain school records for my/our student, including discipline records.
Printed Name of Parent or Guardian*
If 18+, student may complete
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date
NOTE: Hazel Park School District will accept non-resident students without regard to intellect, academics, artistic, athletic, or other ability or talent, mental or physical disability, religion, race, color, national origin, sex, height, weight, or marital status.

FOR OFFICE USE ONLY
Date Received

MonthDayYear
Date
Review Date

MonthDayYear
Date
Status

AcceptedRejected
Administrator

Clear
Date Parent(s) Notified

MonthDayYear
Date
Date of Parent(s) Response

MonthDayYear
Date

Submit
Should be Empty:

REASON FOR ALTERNATIVE HIGH SCHOOL REGISTRATION