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WTCSMid-State
I. STUDENT INFORMATION 













If exact date isn't known, enter 06/01 for month and day. Ex. 06/01/1978












II. COURSE INFORMATION



Example: 10-101-111

III. STUDENT & PARENT /GUARDIAN SIGNATURES (This section should completed by student/parent)


STUDENT SIGNATURE—IN SIGNING THIS DOCUMENT, I acknowledge the following:

·   I understand and will comply with the assurances and conditions outlined in “Student/Parent Specific Responsibilities” and Subchapter 38.12 (14).

·   I authorize the high school and technical college to share course and grade information.

By typing my first and last name in this box, I confirm the data I have provided is accurate and that I understand the information provided on the form.



PARENT/GUARDIAN SIGNATURE—Required if student is under 18.

·   I understand and will comply with the assurances and conditions outlined in “Student/Parent Specific Responsibilities” and Subchapter 38.12 (14)

·   I authorize the high school and college to share course and grade information.

By typing my first and last name in this box, I confirm the data I have provided is accurate and that I understand the information provided on the form.