Fresno: New Student Enrollment Application for ADULTS: 2020-2021

2020 – 2021 ENROLLMENT APPLICATION: For Adult Students Ages 18+: Fresno
Once you have completed this online application you must submit the above documents to your counselor in order to complete your enrollment.

If you are currently homeless, you may be exempt from having to submit all of the above documents prior to enrollment. Please talk to your counselor if you are having trouble obtaining the above documents.

Race & Ethnicity Surveys

New federal race and ethnicity data collection/reporting requirements beginning in 2009-2010 require all students to identify ethnicity from the two choices below.
Is this student Hispanic or Latino? *

No, not Hispanic or Latino Yes, Hispanic or Latino
Race Survey

No matter what ethnicity is selected above, at least one race must also be selected below.
Please select your primary race and secondary race if applicable: *

American Indian or Alaskan Native Black or African American White Middle Eastern Asian Hispanic/Latino Native Hawaiian or Other Pacific Islander

PREVIOUS SCHOOLING INFORMATION:
How many credits has student completed? If you are not sure, provide your best estimate. *
Have you been enrolled in ANY school since August 2014? *

Yes No
List all previous High School(s) you attended (most recent first):

If you have never attended another high school, please write "N/A"
Name of High School #1
City of High School #1
Last year student attended High School #1
Name of High School #2
City of High School #2
Last year student attended High School #2
Name of High School #3
City of High School #3
Last year student attended High School #3
Date STUDENT first enrolled in school in the U.S.: *

Month Day Year
Date
Date STUDENT first enrolled in the California School System: *

Month Day Year
Date
Year that student initially enrolled in 9th grade:

APLUS+ Schools Home Survey
Does the student have access to a computer at home? *

Yes No
Does the student have access to the Internet from home? *

Yes No
How many times has the student's family moved in the past 12 months? *

Release Survey

Please select yes/no from the following: *

Yes

I grant permission for the school to use audio/video of me for school purposes

I grant permission for the school to use pictures of myself for school purposes

I grant permission for the school to use student work produced by me for school purposes

Agriculture and Gifted/Talented Surveys
Is parent/guardian employed in one or more agricultural or fishing activities on a seasonal or other temporary basis? *

Yes No
IF YES, Migration Number:
Have you ever taken a standardized test and been identified as gifted?: *

Yes No
I certify that all of the statements and information given above are true and correct to the best of my knowledge. *

Clear
Date *

Month Day Year
Date

Master Agreement:
YouthBuild Charter School of California is a school of CHOICE. When you sign this agreement, you are agreeing that you choose this school over all others you are entitled to attend or have your child attend. YouthBuild Charter School of California is WASC accredited.
Student’s Full Name (Please Print) *
Effective Date *

Month Day Year
Date
Student's Signature *

Clear
Date *

Month Day Year
Date

STUDENT RELEASE FORM
My Name: *
Age: *
Date of Birth: *

Month Day Year
Date
Address

Street Address

Apt.

City State / Province

Postal / Zip Code
I give permission to YouthBuild Charter School to release my student information to the individuals listed below. This may include attendance records, grade reports, discipline reports and any other information that pertains to my progress.
Name of individual #1
Relationship to individual #1
Name of individual #2
Relationship to individual #2
Name of individual #3
Relationship to individual #3
I am the person named above and am 18 years of age or older. Signature: *

Clear
Date: *

Month Day Year
Date

Emergency Information 2020-21
Student's Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Mailing Address *

Street Address

Apt.

City State / Province

Postal / Zip Code
Physical Address *

Street Address

Apt.

City State / Province

Postal / Zip Code
IN CASE OF EMERGENCY, PLEASE CONTACT:
Name of Emergency Contact#1 and relationship (Ex: mother, sister, etc.) *
Home/Cell Phone of Emergency Contact #1 *
Work Phone of Emergency Contact #1
Name of Emergency Contact #2 and relationship (Ex: father, husband, etc.)
Home/Cell Phone of Emergency Contact #2
Work Phone of Emergency Contact #2

Local Educational Agency Name Housing Questionnaire
Name *

First Name Middle Name Last Name
The information provided below will help the LEA determine what services you and/or your child may be eligible to receive. This could include additional educational services through Title I, Part A and/or the federal McKinney-Vento Assistance Act. The information provided on this form will be kept confidential and only shared with appropriate school district and site staff.
Presently, are you and/or your family living in any of the following situations? Check all that apply.

Staying in a shelter (family shelter, domestic violence shelter, youth shelter) or Federal Emergency Management Agency (FEMA) Trailer Sharing housing with other(s) due to loss of housing, economic hardship, natural disaster, lack of adequate housing, or similar reason Living in a car, park, campground, abandoned building, or other inadequate accommodations (i.e. lack of water, electricity or heat) Temporarily living in a motel or hotel due to loss of housing, economic hardship, natural disaster, or similar reason Living in a single-home residence that is permanent I am a student under the age of 18 and living apart from parent(s) or guardian
Student Name *
Signature - The undersigned certifies that the information provided above is correct and accurate. *

Clear
Date *

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your child or children may have the right to:
- Immediate enrollment in the school they last attended (school or origin) or the local school where you are currently staying, even if you do not have all the documents normally required at the time of enrollment
- Continue to attend their school of origin, if requested by you and it is in the best interest.
- Receive transportation to and from their school of origin, the same special programs and services, if needed, as provided to all other children, including free meals and Title I.
- Redeive the full protections and services provided under all federal and state laws, as it relates to homeless children, youth, and their families
If you have any questions about these rights, please contact the local homeless liaison, Tizoc Brenes, by phone at 213-741-2600 or by email at tbrenes@youtbuildcharter.org

Please list all children currently living with you.

Name

Gender

Birthdate

Grade

School

Child #1

Child #2

Child #3

If you need additional space to list children, you may use the box below:

NONDISCRIMINATION STATEMENT
YouthBuild Charter School of California (YCSC) is committed to providing a working and learning environment free from discrimination, harassment, intimidation, abusive conduct or bullying. YCSC prohibits discrimination, harassment, intimidation, abusive conduct or bullying based on actual or perceived race or ethnicity, gender/sex (including gender identity, gender expression, pregnancy, childbirth, breastfeeding/lactation status and related medical conditions), sexual orientation, religion, color, national origin (including language use restrictions and possession of a driver’s license issued under Vehicle Code), ancestry, immigration status, medical information, physical or mental disability (including clinical depression and bipolar disorder, HIV/AIDS, hepatitis, epilepsy, seizure disorder, diabetes, multiple sclerosis, and heart disease), medical condition (cancer related and genetic characteristics), military and veteran status, parenting status, marital status, registered domestic partner status, age (40 and above), genetic information, political belief or affiliation (unless union related), a person's association with a person or group with one or more of these actual or perceived characteristics, or any other basis protected by federal, state or local law, ordinance, or regulation in any program or activity it conducts or to which it provides significant assistance.

Discrimination is different treatment on the basis of a protected characteristic in the context of an educational program, work or activity without a legitimate nondiscriminatory reason that interferes with or limits the individual’s ability to participate in or benefit from the services, activities, or privileges provided by YCSC or includes an adverse employment action.

Hostile environment harassment occurs when a target is subjected to unwelcome conduct on the basis of a protected characteristic, which is both subjectively offensive to the target and would be offensive to a reasonable person of the protected characteristics under similar circumstances, and is sufficiently severe, persistent, or pervasive so as to interfere with or limit an individual’s ability to effectively work or to participate in or benefit from the services, activities or opportunities offered by YCSC. Harassment may take many forms, including but not limited to, verbal remarks and name calling, graphic and written statements, or any conduct that may be threatening or humiliating. Harassment based on any of the above-protected categories is a form of unlawful discrimination and will not be tolerated by YCSC and can result in disciplinary action against the offending student or employee.

Upon witnessing an act of discrimination, harassment, intimidation, abusive conduct or bullying based on actual or perceived protected characteristics, school personnel are required to take immediate steps to intervene when it is safe to do so. Once a school/office has express notice or reason to know of such conduct, whether carried out by employees, students or third parties, it should take immediate and appropriate steps to investigate or otherwise determine what occurred and take prompt and effective steps reasonably calculated to end the conduct, eliminate a hostile environment, if one has been created and prevent the conduct from occurring again. These steps should be taken regardless of whether an individual makes a complaint or asks the school/office to take action. Complainants are protected from retaliation. YCSC prohibits retaliation against any person who files a complaint or an appeal, reports instances of noncompliance, discrimination, harassment, intimidation, abusive conduct or bullying, or who participates in the complaint-filing or investigation process. This nondiscrimination policy applies to all acts related to school activity or school attendance within any school/office under the jurisdiction of the Superintendent of YouthBuild Charter School of California.

For inquiries or complaints related to discrimination, harassment, intimidation or bullying of students based on actual or perceived protected characteristics, contact the Title IX/Bullying Complaint Manager:

Dr. Rudy Cuevas 155 W. Washington Blvd. Suite 944 Los Angeles, CA 90015 213.741.2600. ext. 205

For inquiries or complaints related to employee-to-employee, student-to-employee, or work/employment related discrimination, harassment, abusive conduct or intimidation, contact your Human Resources Department.
Should be Empty:

2020 – 2021 ENROLLMENT APPLICATION: For Adult Students Ages 18+: Fresno

Once you have completed this online application you must submit the above documents to your counselor in order to complete your enrollment.

STUDENT INFORMATION:

Race & Ethnicity Surveys

Race Survey

PREVIOUS SCHOOLING INFORMATION:

List all previous High School(s) you attended (most recent first):

PARENT EDUCATION LEVEL SURVEY:

Home Language Survey

Dashboard Alternative School Status (DASS)

APLUS+ Schools Home Survey

Household Income Data Collection Form

Release Survey

Special Education Services/ 504 Plan

Please sign below only if you have NEVER been in a Special Education Program

Please sign in the appropriate section below ONLY if you currently have or have ever had an IEP or 504 Plan.

Agriculture and Gifted/Talented Surveys

Master Agreement:

STUDENT RELEASE FORM

Emergency Information 2020-21

IN CASE OF EMERGENCY, PLEASE CONTACT:

HEALTH INFORMATION:

Local Educational Agency Name Housing Questionnaire

NONDISCRIMINATION STATEMENT