PASS School
*Positive Alternative For Student Success

Application/Student Enrollment Form

Return this Application to North Campus, Guidance Office
 

Name ______________________________________ Grade______

Address ________________________________________________

Live With (name)  _____________________ Relationship ________

Home Phone ______________  Parent Work Phone _____________

Birthdate ___________   Last School Attended _________________


 

PASS does not provide transportation . How do you intend to get to PASS?

Parents ______ Drive self ______Car Pool With ___________________

The MCC campus has a 15 mph speed limit.
Students who speed or drive in an unsafe manner will have their parking privileges revoked.
 

Currently Employed With ______________________________________

Scheduled Hours/Days Working__________________________________

 

 Complete the Following Carefully.  Your acceptance may depend upon it.

1.  Why do you want/need to attend PASS School?
 

 
 

2.  Are there special circumstances that would make it difficult for you to succeed at Kingman High School which make an alternative school necessary for you?
 
 
 

 

3.  PASS School offers both freedom and responsibility.  In what ways have you demonstrated responsibility in your life?
 
 


 


List the names and phone numbers of two adult references:

1.  _______________________________________

2.  _______________________________________

List any PASS student references:

_______________________________________

_______________________________________

     

    I understand that if selected to participate in PASS School, my satisfactory continuance in the program requiresthe following commitments:

  • Responsibility:  I will show responsibility by taking control of my education and being aware of what I need to accomplish weekly to meet my graduation goals.
  • Respect:  I will show respect not only for myself, but also for my classmates and teachers.
  • Cooperation: I will show cooperation by actively participating in the learning experience given to me.
  • Attendance: I will keep my absences under the minimum and call in if absent.
  • Behavior: I will follow all PASS rules.
  • Academics: I will do my best on all assignments and tests, use PASS time wisely, and do the most work I can per week.

________________________________  ____________
           Student Signature              Date


    I understand that I need to make the following commitments to ensure my son/daughter's success at PASS School if he/she is selected for participation:
  • I agree to attend scheduled conferences as needed.
  • I agree to look over Progress Reports every Monday and provide support and encouragement to stay in school.
  • I agree to encourage my son/daughter to attend PASS daily except for illnesses, and to schedule work and other commitments so PASS minimum time can be attended weekly.
  • I understand students will be placed on contract for 4 Negative Reports for lack of work, attendance, or poor behavior.
  • I understand students receiving 5 Negatives will be dropped from PASS.
  • I agree with the commitments my son/daughter has made for participation in PASS School.


________________________________  ____________
     Parent/Guardian Signature           Date


Continued enrollment at PASS will be determined each semester by academic performance, attendance and behavior
 
 

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