MPCP-7 MPCP Student Application Designee Authorization
|[pic] |Wisconsin Department of Public Instruction |INSTRUCTIONS: Complete one form per school. Email to: |
| |PRIVATE SCHOOL CHOICE PROGRAMS (PSCP) |privateschoolchoice@dpi. |
| |STUDENT APPLICATION | |
| |DESIGNEE AUTHORIZATION |Collection of this information is a requirement of |
| |PCP-111 (Rev. 08-17) |Wis. Stat. §§119.23 and 118.60 and |
| | |Wis. Admin. Code PI 35 and PI 48. |
|PLEASE TYPE OR PRINT | |
| |I. GENERAL INFORMATION | |
|Name of School |Phone Area/No. |Effective Date Mo./Day/Yr. |
| | | |
|Choice Administrator |E-Mail Address |Today’s Date Mo./Day/Yr. |
| | | |
|Street Address |City |State |ZIP |
| | | | |
| |II. DESIGNEE INFORMATION | |
|The designee(s) named below has been authorized to certify PSCP student applications and have access to the PSCP online application system for the school named |
|in Section I beginning on the effective date indicated in Section I. |
|Name of Authorized Designee |E-Mail Address |Phone Area/No. |
| | | |
|Designee Address Other Than School Address Street, City, State, ZIP |
| |
|I CERTIFY AND ACKNOWLEDGE, BY SIGNING THIS FORM, that if the private school is barred or terminated from the program, I may be prohibited from having an |
|ownership interest in or serving as an officer, director, trustee, administrator, administrator designee, or person responsible for administrative, financial, |
|or pupil health and safety matters, for compensation or as a volunteer, at another private school participating in the choice program, for seven years from the |
|date of the state superintendent’s order barring or terminating the private school from the program. |
|Signature of Authorized Designee |Date Signed Mo./Day/Yr. |
|( | |
|Name of Authorized Designee |E-Mail Address |Phone Area/No. |
| | | |
|Designee Address Other Than School Address Street, City, State, ZIP |
| |
|I CERTIFY AND ACKNOWLEDGE, BY SIGNING THIS FORM, that if the private school is barred or terminated from the program, I may be prohibited from having an |
|ownership interest in or serving as an officer, director, trustee, administrator, administrator designee, or person responsible for administrative, financial, |
|or pupil health and safety matters, for compensation or as a volunteer, at another private school participating in the choice program, for seven years from the |
|date of the state superintendent’s order barring or terminating the private school from the program. |
|Signature of Authorized Designee |Date Signed Mo./Day/Yr. |
|( | |
|Name of Authorized Designee |E-Mail Address |Phone Area/No. |
| | | |
|Designee Address Other Than School Address Street, City, State, ZIP |
| |
|I CERTIFY AND ACKNOWLEDGE, BY SIGNING THIS FORM, that if the private school is barred or terminated from the program, I may be prohibited from having an |
|ownership interest in or serving as an officer, director, trustee, administrator, administrator designee, or person responsible for administrative, financial, |
|or pupil health and safety matters, for compensation or as a volunteer, at another private school participating in the choice program, for seven years from the |
|date of the state superintendent’s order barring or terminating the private school from the program. |
|Signature of Authorized Designee |Date Signed Mo./Day/Yr. |
|( | |
| |III. SCHOOL SIGNATURE | |
|I CERTIFY that this information is true and correct to the best of my knowledge and the designee(s) named herein has been authorized to certify PSCP student |
|applications and have access to the PSCP online application system for the school named in Section I beginning on the effective date indicated in Section I. |
|Signature of Choice Administrator |Date Signed Mo./Day/Yr. |
|( | |
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