MMSA Form

Student First Name:

Student Last Name:

Grade:

Student Date of Birth:

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Guardian First Name:

Guardian Last Name:

Guardian Cell Phone

Guardian E-mail

Date / Time

ENROLLMENT CHECKLIST

The Following documents are required to complete your student's enrollment:

Student Enrollment Form
Proof of Address
Birth Certificate (or) Social Security Card
Last Report Card/Grade Verification with Discipline Records (End of the year)
IEP (If applicable)
Immunization Records *

I acknowledge that the above items are required to complete my student's enrollment

Yes

Student Information

*Please Note: To be eligible for 4-year-old kindergarten, a child must be 4 on or by September 1 of the school year. To be eligible for 5-year-old kindergarten, a child must be 5 on or by September 1 of the school year.

First Name

Middle Name

Last Name

Mother's First Name

Middle Name

Last Name

Father's First Name

Middle Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Parent's Cell Phone

Parent's Work Phone

Parent's Home Phone

Parent's E-mail

Student's Date of Birth

City of Birth

State of Birth

Student's Gender

Male

Female

Student's Grade Applied (Please Mark One)

First

Second

Third

Fourth

Fifth

Sixth

Seventh

Eigth

Prior to Our School, the Student has Attended:

Previous School's Name

Phone

Address Line 1

Address Line 2

City

State

Zip Code

Student has an IEP?

Yes

Lunch Status According to the Federal Meal Program:

Free

Reduced

Full Pay

Not Nown

Will your child(ren) need school-provided transportation for the 2024-2025 school year?

Yes

Student Housing Information

The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness.
If you own/rent your own home, you do not need to complete this form.

Student is:

Student is unaccompanied (not living with a parent or legal guardian)

Student is living with a parent or legal guardian

If you do not own/rent your own home, please check all that apply below.

In a motel

A car, park, campsite, or similar location

In a shelter

Traditional Housing

Moving from place to place / couch surfing

In someone else's house or apartment with another family

In a residence with inadequate facilities (no water, heat, electricity, etc.)

Other

Address of current residence:

Address Line 1

Address Line 2

City

State

Zip Code

Ancestry / Ethnic Origins and Tribal Affiliation Data

Is the person Hispanic or Latino

Hispanic or Latino

Not Hispanic or Latino

Optional Question I-A: If Hispanic or Latino was chosen above, select all that apply from the list below:

Columbian

Mexican

Spaniard / Spanish / Spanish American

Ecuadorian

Puerto Rican

Guatemalan

Salvadoran

Decline to Indicate

Other

Unknown

Race Designation

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Optional Question II-A: If chosen, select all that apply from the list below:

Bad River BAnd

Lac Courte Oreilles

Oneida Nation (Wisconsin)

St. Croix

Forest Country

Lac du Flambeau

Red Cliff

Stockbridge

Ho-Chunk

Menominee

Sokaogon

Brothertown

Other

Optional Question II-B: If chosen, select all that apply from the list below:

Burmese

Hmong

Korean

Chinese

Indian

Vietnamese

Filipino

Karen

Unkown

Other

Decline to indicate

Optional Question II-C: If chosen, select all that apply from the list below:

African American

Liberian

Ethiopian-Oromo

Nigerian

Ethiopian-Other

Somali

Unknown

Other

Decline to Indicate

Parent Information

Primary Parent or Guardian Information

Relation to the Student

Does This Person have Legal Custody of the Student?

Yes

First Name

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Secondary Parent or Guardian Information

Relation to the Student

Does This Person have Legal Custody of the Student?

Yes

First Name

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Student's Sibling Information

1st Full Name

Age

School

2nd Full Name

Age

School

3rd Full Name

Age

School

4th Full Name

Age

School

Emergency Contacts - to be reached when the school is NOT able to reach the parents

Relation to the Student

First Name

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Work Phone

Home Phone

Relation to the Student

First Name

Last

Able to Pick Up Student

Yes

Cell Phone

Work Phone

Home Phone

Secondary Contact's Relation to the Student

First Name

Last

Able to Pick Up Student

Yes

Cell Phone

Work Phone

Home Phone

How Did You Hear About Us?

Why Did You Choose Us?

Wisconsin law requires that each student provide a certified copy of any child custody order or decree which has been issued with respect to the student. The custodial parent of such a student must also provide the board of education with certified copies of any later court orders which modify the original custody order or decree.

Please check one of the following statements that applies to your child:

Child lives with natural or legally adoptive parent(s).

Parents are divorced or legally separated; child resides with parent that has legal custody by court order. (If this is your situation, you must provide the school with a copy of the court order.)

Parents are divorced or legally separated; child resides with parent that DOES NOT have legal custody. (If this is your situation, you must provide the school with the legal documents that permit this arrangement.)

Child lives with a Guardian who has been granted legal custody by court order. (If this is your situation, you must provide the school with a copy of the court order.)

Child lives with a Guardian who HAS NOT been granted legal custody by court order. (If this is your situation, you must provide the school with the legal documents that permit this arrangement.)

Child lives with Foster Parents. (If this is your situation, you must have a representative of the custodial agency with you and all necessary court orders at the time you present this application to the school.)

I hereby by agree to provide Milwaukee Math and Science Academy with any custody papers that may exist currently or in the future and provide updated versions promptly if requested by the State of Wisconsin or local school District. We/I, the undersigned, hereby certify that, to the best of our/my knowledge and belief, the answers to the foregoing questions and statements made by us/me in this application are complete and accurate. We/I understand that any false information, omissions, or misrepresentations of facts may result in rejection of this application or future dismissal of the applicant.

Home Language Survey

As required by federal law, this form must be completed for all students at the time of enrollment. (Title VI Compliance)

Name of Student

DATE OF BIRTH

PLACE OF BIRTH

City

State

NAME OF GUARDIAN:

LAST

Student’s English Language Proficiency:

Native English Speaker

Limited (English Language Learner)

Please answer the following questions:

What language did your son/daughter speak when he/she first learned to talk?

What language do you use most frequently with your son/daughter?

What language does your son/daughter use most frequently at home?

What language do the adults at home most often speak?

How long has your son/daughter attended school in the United States?

Parent in Military

1. Is either parent or guardian on active duty in the military?

Yes

2.Is either parent or guardian a traditional member of the Guard or Reserve?

Yes

3. Is either parent or guardian a member of the Active Guard/Reserve (AGR) under Title 10 or full time National Guard under Title 32?

Yes

Request For Records

Permisson to Release Permanent School Records

Parent's Name

Middle Name

Last Name

Student's Name

Middle Name

Last Name

Student's Date of Birth

I, do attest that I am the parent / legal guarding of, the student specified, whose date of birth is given as above. I have withdrawn my student from the school given above.

School Name

Today's Date

Milwaukee Math and Science Academy
2703 N. Sherman Blvd.
Milwaukee, WI 53210
Attn: RECORDS

Please send the all of the information listed below, if applicable:

Grades & Academic Records
Psychological Assessment & Records
Disciplinary Records
Attendance Records
Medical/Immunization Records
All Testing Results and/or EvaluationsAll Special Education Records/Info (IEP, MFE, Parent Permission, Prior Written Notice, etc.)

Parent permission is no longer required when requested by authorized school personnel. US DEPARTMENT OF EDUCATION; FEDERAL EDUCATIONAL RIGHTS AND PRIVACY ACT. 34 CFR § 99.31

1st Request

Date

2nd Request

Date

3rd Request

Date

Previous School's Fax #

The student’s first day of attendance at Milwaukee Math & Science Academy will be on:

Medical Consent

Emergency Medical Authorization Purpose:

This form is to enable parents and guardians to authorize the provision of emergency treatment for the child who gets ill or injured within the school authority when you are inaccessible.

Student's Full Name

Birth Date (mm/dd/yy)

Grade

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Student Resides With (Please Mark):

Mother

Father

Sibling

Guardian

Grandparent

Stepparent

Parent / Guardian's Cell Phone

Work Phone

Medical History

Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments of which a physician/ school personnel should be informed: (Please Specify Below)

Please Select On of the following:

Consent for Treatment

Refusal to Consent

Preferred Dentist's Name

Preferred Physician's Name

Medical Specialist's Name

Preferred Hospital

Phone

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the preferred doctor indicated, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

I agree (Parent or Guardian's Consent)

Today's Date

I disagree (Parent or Guardian's Consent)

I do not give consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following actions: (Please Specify Below)

Today's Date

Internet Access at Home Survey

Question 1: Can the student access the internet on their primary learning device at home?

Yes

No - Not Available

No - Not Affordable

No - Other

Question 2: What is the primary type of internet service used at the residence?

Residential Broadband (e.g. DSL, Cable, Fiber) (Spectrum - AT&T - Verizon)

Cellular Network (Phone Hotspot)

School Provided Hotspot

Satellite

Dial-up

Other

None

Question 3: Can the student stream a video on their primary learning device without interruption?

Yes - No issues

Yes - But not consistent

Question 4: What device does the student most often use to complete schoolwork at home?

Desktop / Laptop

Tablet

Chromebook

Smartphone

None

Other

Question 5: Is the primary learning device a personal device or school-provided device and is it shared with anyone else in the household?

Personal - Dedicated (dedicated device for the student)

Personal - Shared (sharing device with others in the household)

School Provided - Dedicated

School Provided - Shared

None

Parent Permission / Photo Release

From time-to-time Milwaukee Math and Science Academy is fortunate to have news articles related to some of our activities. The coverage may be newspapers or television stations. During this coverage, pictures and /or names of students may be used. From time to time we also use students’ pictures in newsletters, brochures and informational videos of Milwaukee Math and Science Academy. We also publish our school related pictures and illustration on our web site, mmsacademy.org and or conceptschools.org. We will permit this as long as the coverage is positive and personal information is not included without your permission.

According to the terms listed above, please check one of the following:

Yes - Milwaukee Math and Science Academy has permission to use my child’s name/picture for videos, newspaper, television, school websites and brochures.

No - Milwaukee Math and Science Academy may never use my child’s name/picture for press release.

Student's Full Name

I agree (Parent or Guardian's Consent)

Today's Date

Immunization Information

Student's Full Name

Section 3313.671 requires children of school age to be immunized against Varicella (chickenpox), Diphtheria, Whooping Cough, Tetanus, Polio, Rubeola, and Mumps.

Please provide a COPY of the most recent Immunization records

Varicella (mm/dd/yy)

DPT (mm/dd/yy)

DT (mm/dd/yy)

OPV (mm/dd/yy)

Hepatitis B (mm/dd/yy)

Polio (mm/dd/yy)

Rubeola (mm/dd/yy)

Rubella (mm/dd/yy)

Mumps (mm/dd/yy)

MMR II (mm/dd/yy)

TB Test (mm/dd/yy)

Result

Positive

Negative

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

I agree (Parent or Guardian's Consent)

Today's Date

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Application Form

ENROLLMENT CHECKLIST

The Following documents are required to complete your student's enrollment:

Student Information

Prior to Our School, the Student has Attended:

Student Housing Information

Ancestry / Ethnic Origins and Tribal Affiliation Data

Parent Information

Primary Parent or Guardian Information

Secondary Parent or Guardian Information

Student's Sibling Information

Emergency Contacts - to be reached when the school is NOT able to reach the parents

Home Language Survey

Parent in Military

Request For Records

Milwaukee Math and Science Academy2703 N. Sherman Blvd.Milwaukee, WI 53210Attn: RECORDS

Please send the all of the information listed below, if applicable:

Parent permission is no longer required when requested by authorized school personnel. US DEPARTMENT OF EDUCATION; FEDERAL EDUCATIONAL RIGHTS AND PRIVACY ACT. 34 CFR § 99.31

Medical Consent

Internet Access at Home Survey

Parent Permission / Photo Release

Immunization Information

** Please provide a COPY of the most recent Immunization records **

Want to Hear From Us?

Milwaukee Math and Science Academy
2703 N. Sherman Blvd.
Milwaukee, WI 53210
Attn: RECORDS

Please provide a COPY of the most recent Immunization records