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Home > Admission > Online Forms > Admission Application Form

Admission Application Form

* Fields marked with an asterisk are required.

Applicant Information

Full Name *

Preferred Name *

Date of Birth *

Age *

Gender *

Male
Female

Country of Citizenship *

Current Grade *

Applying for Grade *

For School Year *

Applicant's Address *

Home Phone *

Cell Phone *

Applicant Email

Ethnic Background: MPH is committed to diversity. Your response is optional.

White
Black/African American
American Indian/Alaskan
Asian/Pacific Islander
Hispanic/Latino
Middle Eastern
Multiracial

Family Information

Parent/Guardian Full Name *

Social Security Number *

Relationship to Applicant *

Address (if different from applicant)

Home Phone (if different from applicant)

Cell Phone *

E-mail *

Occupation/Title *

Employer *

Business Address

Business Phone

Second Parent/Guardian Full Name

Social Security Number

Relationship to Applicant

Address (if different from applicant)

Home Phone (if different from applicant)

Cell Phone

E-mail

Occupation/Title

Employer

Business Address

Business Phone

Family Status

Parents are *

Married
Single
Separated
Divorced
Remarried
Mother Deceased
Father Deceased

Student Residential Status

Student lives with *

Both Parents
Mother
Father
Stepmother
Stepfather
Other

If other was chosen, please provide name

Family & Friends

Sibling 1 Name

Sibling 1 Age

Sibling 1 Grade

Sibling 1 School

Sibling 2 Name

Sibling 2 Age

Sibling 2 Grade

Sibling 2 School

Sibling 3 Name

Sibling 3 Age

Sibling 3 Grade

Sibling 3 School

Please list any realtives or friends who have attended MPH

Financial Information

Financial responsibility will be assumed by *

Are you applying for financial aid? *

Yes
No

School Information

Applicant's Current School *

Current School Address *

Current School District *

Grades Attended *

Please list all previous schools attended with grades and years *

Has applicany been dismissed from any school for any reason? *

Yes
No

If yes, please explain

Has your child had an educational evaluation or assesment of intellectual functioning in the last three years? *

Yes
No

Would you be willing to share this information to help us better understand your child's needs?

Yes
No

Please list the names of those sending recommendations *

Special Interests

Please indicate the applicant's special interests *

Music
Art
Theater
Dance
Sports
Technology

Please describe applicant's special interests *

How did you learn about MPH? *

Friend/Relative
MPH Parent/Student
Newspaper
Internet
Open House
MPH Web Site
Word of Mouth
Realtor

Parent Statement

Please comment on why you would like your child to attend MPH. What areas of strength and talent would you hope to see further developed at MPH? What do you perceive to be your child's area of greatest need? *

Application Date *

I have mailed the $50 application fee to MPH *

Yes
No

Optional: I have emailed or mailed a recent photo of my child to Nicole Cicoria at ncicoria@mph.net

Yes
No

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Contact Us

For more information, please contact:

Nicole Cicoria
Director of Admissions
315/446-2452, ext. 131
ncicoria@mph.net

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mphinfo@mph.net • 315-446-2452 • 5300 Jamesville Road | DeWitt, New York 13214
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