McDowell Connect Interest Form
McDowell County Schools
Student Information
Student Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home School Name
School Level
Grade
Home School License Number
Private School Name
School Level
Grade
Tell us something about yourself.
*
Student
Skills, Talents, and Hobbies
*
Student
Please upload your recent photo
*
Browse Files
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Does the student have any disabilities, illness, medical conditions, etc. that can affect his/her virtual attendance?
*
Parent/Guardian Details
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Relationship
*
Others
How did you learn about this virtual course?
*
Facebook
Twitter
YouTube
MCS Webpage
Referral
Brochure
Other
Any additional comments or information you would like to share?
*
Date Signed
*
-
Month
-
Day
Year
Date
Print Form
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