Name of Charter School:  YouthBuild Philadelphia Charter School                      

Address: 1231 North Broad Street Philadelphia, PA 19122                                

Charter School Contact Person: Anna Latshaw, Program Operations Manager     

Telephone: 215-627-8671, ext. 25                                                                 

Email Address: admissions@youthbuildphilly.org                                              

I. Student Information

II. School District of Residence and Former School Information

School District of Residence: Philadelphia                                                             

 

Page 1 of Charter School Student Enrollment Notification Form                                            PDE2002

Intructions for this can be found at www.pde.state.pa.us. Under the K-12 Schools folder, click on Public Schools, then Charter School, then Reporting.

III. Parent/Guardian Information:

Complete Parent / Guardian Name and Address Information as applicable.

If you are in touch with only one parent or guardian you need only provide their information. 

If the Student Is Not Living With Parents, Please Complete This Section.

 If you live at the address of your parent or guardian listed above you do NOT need to complete this section.

My signature on this form inficates my decision to have my student attend this charter school named on page 1 of this form and signifies my request that appropriate school records be forwarded from the school district to the charter school.

 Official Enrollment Date:  9/07/2021  Anticipated Date of Attendance:   8/31/2022   

Grade Student is Entering:   12     

Page 2 of Charter School Student Enrollment Notification Form                                            PDE2002

Instructions for this can be found at www.pde.state.pa.us. Under the K-12 Schools folder, click on Public Schools, then Charter School, then Reporting.

1231 N Broad Street 

Philadelphia, PA

19122

Grade: ______12th_______

Pennsylvania School Code Section 13-1304-A states in part “Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether the pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other state for an action of offense involving a weapon, alcohol or drugs, or the willful infliction of injury to another person, or for any act of violence committed on school property.” 

I hereby swear or affirm (please answer the following questions) -

 

My child is presently suspended or expelled from any public or private schools in this Commonwealth or any other state for an action of offense:

If this student is presently suspended or expelled from another school, please complete:

My child was (in the past) suspended or expelled from any public or private school of this Commonwealth for an action of offense:

If this student was (in the past) suspended or expelled from another school, please complete:

I make this statement subject to the penalties of 24 P.S. Section 13-1304-A(b) and 18 Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, information and belief.

Any willful false statement made above shall be a misdemeanor of the third degree.
This form shall be maintained as part of the student’s disciplinary record.

The Office of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for the identification.

School: YouthBuild Philadelphia Charter School

Grade: ____12____

*YouthBuild Philadelphia Charter School has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, YouthBuild Philadelphia Charter School has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, YouthBuild Philadelphia Charter School may conduct screenings or ask for related information about students who are already enrolled in the district as well as from students who enroll in YouthBuild Philadelphia Charter School in the future.

1231 N Broad Street

Philadelphia, PA

19122

Rebuilding Lives and Communities

www.youthbuildphilly.org

Grant Year: 2021 -2022

As a student at YouthBuild you are also a minimum-time or quarter-time AmeriCorps member. The Corporation for National & Community Service, which oversees the AmeriCorps program, requires that all AmeriCorps members have a series of background checks completed before the start of their term of service. The results of the background checks determine whether or not a person is able to serve as an AmeriCorps member and what type of service they are permitted to do. 

**The background check results do not, however, affect your eligibility to enroll as a YouthBuild student.**

 

As an applicant for an AmeriCorps position, the following required criminal history checks are required before beginning a term of service:

PA State Police Criminal Registry Check
FBI Fingerprint Criminal History Check (required for any members who will have recurring access to vulnerable populations)
Home State Criminal Registry Check (if the applicant resides outside of PA)
If an out of state applicant, please fill in the name of the home state: N/A
PA Dept. of Public Welfare Childline Child Abuse Check (required for any members who will have recurring access to vulnerable populations)
National Sex Offender Public Registry (NSOPR) Check
 

Please read the following statement:

As an applicant for an AmeriCorps member position, I understand and acknowledge that my acceptance as an AmeriCorps member is subject to the results of each of the aforementioned criminal history checks. 

Refusal to consent to the above checks makes me ineligible to serve. 

Anyone listed or required to be listed on a sex offender registry is ineligible to serve. 

Anyone convicted of murder is ineligible to serve. 

I understand that if assigned to a position with recurring access to vulnerable populations, I am not permitted to have unsupervised access to children, persons age 60 and older, or individuals with disabilities while waiting for the results of my criminal history checks.

You will have the opportunity to review all criminal history clearance results with program staff.

 

With my signature I confirm that I understand and acknowledge all of the above statements and give my consent for YouthBuild Philadelphia Charter School staff to conduct the aforementioned criminal history checks: