Student Information
First Name: *	MI:	Last Name: *	Birthday: *
Address: *	City: *	State: *	Zip: *
Home Phone:(xxx-xxx-xxxx)	Cell Phone:(xxx-xxx-xxxx) *	Email Address: *
Gender:*Male Female	USCitizen:*Yes No	Hispanic/Latino:*Yes No
Ethnicity/Race:*American Indian or Alaskan Native Asian Black or African American Choose not to reply Hispanic/Latino Native Hawaiian or Other Pacific Islander White

High School Information

Home High School: Abraham Lincoln Adair Casey-Guthrie Center High School Adel-DeSoto-Minburn High School AHSTW High School Ames High School Ankeny Centennial High School Ankeny Christian Academy Ankeny High School Ankeny Northview Middle School Ankeny Southview Middle School Ar-We-Va High School Atlantic High School Audubon High School Ballard-Huxley High School Baxter High School Bondurant-Farrar Community High School Boone High School Carlisle High School Carroll High School Clarke Community High School Colfax-Mingo High School Collins-Maxwell Community School Colo-Nesco High School Coon Rapids-Bayard High School Dallas Center-Grimes High Sch Denver High School Des Moines Christian Des Moines Virtual Campus Dowling Catholic High School Earlham High School East High School East Marshall High School East Sac County High School Exira Community Jr-Sr High School Fremont Mills Gilbert Community School Glidden-Ralston High School Grand View Christian School Grinnell High School Harlan High School Hoover High School IKM-Manning High School Indianola High School Interstate 35 Community HS Johnston High School Johnston Middle School Knoxville High School Kuemper Catholic High School Lynnville-Sully High School Madrid High School Martensdale-St Marys Comm Sch Melcher-Dallas High School Nevada High School Newton High School North High School North Polk Jr-Sr High School Norwalk Community High School Ogden High School Okoboji High School Ottumwa High School Panorama Community High School Pella Christian High School Pella High School Perry Alternative School Perry High School Pleasantville High School Prairie City-Monroe High School Roland-Story High School Roosevelt High School Saydel Sr High School Shenandoah High School South Central Calhoun Southeast Polk High School Southeast Warren Jr-Sr HS Test High School Twin Cedars High School Urbandale High School Valley High School - West D M Van Meter High School Walnut Creek Campus Alt Wapsie Valley High School Waukee Community High School Waukee Northwest Community High School West Central Valley High School West Marshall Community School Winterset High School Woodward-Granger High School *

Grade Level: Select.. Freshman Sophomore Junior Senior *

DMACC Class Schedule Information
Semester: Fall (August – December) Spring (January – May)		Year:

Authorization for Registration
* By checking this box I understand I am enrolling in DMACC credit course(s). An official DMACC transcript will be generated and become a part of my permanent academic record. I also understand this request will be routed to my High School Instructional Coach for final approval.
* I understand, if I have an IEP and/or 504 plan, that I must complete the DMACC Disabilities Services Application for Accommodation in order to be considered for the appropriate accommodations.
* I understand it is my responsibility to provide transportation to and from the academy and any respective work sites.
* I have discussed enrolling with my parent and/or guardian and they have given approval for my enrollment into the career academy.