Applicant Name:

First
Middle
Last
Name I go by:
Applicant's Email Address:

Applicant's Home Address:

Address
City
State
Zip Code
Applicant lives with	both parents mother father other

Applicant's Phone Numbers:

Home
Cell

Prior School Info

High school you are currently zoned for:
Current school you are attending
Current grade you are in
If your present school is not part of Bay District School, please list address, phone number, and contact person.
Has applicant ever skipped a grade?	Yes No What grade? Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade Seventh Grade Eighth Grade
Has applicant ever repeated a grade?	Yes No If yes, what grade? Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade Seventh Grade Eighth Grade

Other Info

Are there any health or education needs of which we should be aware?
Please list other children in your family who attend Mosley:

Father/Male Guardian's Name

First
Middle
Last

Father/Male Guardian's Home Address

Address:
City
State
Zip Code

Father/Male Guardian's Phone Numbers & Email Address

Home Phone
Business Phone
Place of Employment
Cell Phone
Email Address

Mother/Female Guardian's Home Address

First
Middle
Last

Mother/Female Guardian's Home Address

Address:
City
State
Zip Code

Mother/Female Guardian's Phone Numbers & Email Address

Home Phone
Business Phone
Place of Employment
Cell Phone
Email Address

Please respond to one of the following statements below. Your answer will be evaluated for content and style. Your answer should show intelligent thought, careful workmanship, clear organization, good sentence structure, proper grammar, correct spelling, and correct punctuation. The response should not be longer than 500 words.

Complete one of the following statements:

• The person who has most influenced my life...
• My leadership potential is best demonstrated by...

We strongly suggest that you type your Writing Sample in a word processor, and then copy and paste the writing sample.
Writing Sample:

In order of importance to you, list below significant extracurricular activities, clubs, and organizations in which you have participated in school or the community. Please indicate whether you held any leadership positions.

If you answer yes to the following question, you must submit a full statement of relevant facts in the space provided below. Answering yes will not automatically disqualify you for admissions to MAPPS. If you are unsure whether you should answer yes, we strongly suggest that you answer yes and fully disclose all incidents to avoid future revocation of your offer of admission.

Have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any school during the past two years? Yes No

If yes, please fully disclose all incidents to avoid future revocation of your offer of admission.