High School Application

Name*
First Last
High School*
Current Grade Level*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Student Phone Number*
Can we communicate with you by text message?*
- Yes
- No
Student Email Address*
Parent/Guardian Name*
First Last
Parent/Guardian Phone Number*
Parent/Guardian Email Address*
Mid-Del Tech Program Selection*
*Students selecting Medical Assistant/Nursing must be 18 by January of Senior year due to clinical sites.
Why did you select that MDTC program?*
What are your plans after high school?*
Please list any clubs, organizations, volunteer or work experience below.