STEDY Online Application - STEDY - Southwest Technical Education District of Yuma

Student Phone Number: *

Student Phone Number is required

Student Lives With:

Gender: *

Gender is required

Race: *

Race is required

Student E-Mail: *

Student E-Mail is required

Current Grade Level: *

Grade Level is required

Anticipated Graduation Date: *

Graduation Date is required

High School ID#:

High School Counselor:

Student SAIS Number: (You may obtain this from your counselor)

Home High School: *

Please select a high school

Program: *

Please select a program

Special Accommodations: *

Is the Student eligible for special education and related services?

If YES, please provide a copy of the Student's current Individualized Education Plan (IEP) or 504.

Please indicate YES or NO

Please indicate if your student has any of the following health conditions: (check all that apply)

ADD/ADHD

Allergies

Endocrine Disorder

Asthma

Diabetes

Migraines

Gastrointestinal

Heart Condition

Hearing/Ear Disorder

Vision (Glasses/Contact)

List any treatments, including medication(s) taken:

How did you hear about STEDY?:*

Please tell us how you learned about STEDY

T-Shirt Size:*

T-Shirt Size is required

Other (Please Specify):

Emergency Contact Name: *

Emergency Contact Name is required

Relation: *

Relation is required

Phone Number: *

Emergency Contact Phone Number is required

Parent Name: *

Parent Name is required

Parent E-Mail: *

Parent Email is required

Home / Mobile Phone:*

Parent Phone is required

Mailing Address: (if different)

City:

State:

Zip:

* = required fields

Parent Signature: *

Draw your signature in the box below:

Signature is required

STEDY Admission Application

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Thank You For Submitting The STEDY Online Admission Application.