NOTE: Under AB216, if you checked any of the above, you may be eligible to graduate by completing the minimum state requirements. For eligibility determination, please see your academic counselor for additional information.
In case of accident or other emergency, if parent or guardian cannot be reached, I hereby authorize a representative of the school to make arrangements considered necessary for my student to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such acts and treatment of my student, as he/she considers necessary. In the event said doctor is not available, I authorize care and treatment to be performed by any licensed physician or surgeon.
The undersigned hereby agree to bear all costs incurred as a result of the forgoing. This authorization will remain in effect until revoked by the undersigned in writing.
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.
Your child or children may have the right to:
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 firstname.lastname@example.org.
This letter is intended to inform and request your consent for yourself or your son/daughter to receive counseling services at our school site. The MSW interns along with a licensed clinician will provide assistance through case management, one-on-one counseling, crisis intervention, behavioral counseling, group counseling, telehealth, and workshops. If a need for treatment beyond the scope of services provided on site arises, you will be contacted to consent for such services. The intent is to provide support for yourself and/or your son/daughter, the school, and your family. The intern will complete documentation including progress notes, psychosocial assessments, and goals and is kept in a HIPAA compliant electronic records system. The intern will only be working with the student until the end of the school year unless the student voluntarily discontinues the service. At the end of the intern’s internship the intern will end communication with clients in order to ensure confidentiality.
The intern works on a team with school staff and will need to notify staff of the working relationship between the intern and student and the basic services offered to the student. No other specific information regarding sessions will be provided to the school unless verbal consent is given by the student to do so.
Electronic communication is allowed between MSW interns and clients for appointment/attendance reminders and for counseling sessions. Clients may not engage in electronic communications with interns outside of regular school day or for any other therapeutic reason including crises.
During the process of providing these services all information exchanged will be kept confidential. Protected health information will not be shared with anyone outside of the school unless you or your son/daughter and/or parent sign a consent authorizing release of information.
The following are exceptions to this policy:
If you have any questions or need further clarification please feel free to ask.
I,type name here* hereby certify that I have read the above and understand that I may meet with an MSW intern for counseling services. Itype name here* hereby certify that I understand the limitations of confidentiality and electronic communications..
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.