San Bernardino New Student Enrollment Application for Minors: 2022-23 (UNDER 18)

San Bernardino New Student Enrollment Application for Minors: 2022-23
Dear Prospective Student,

Thank you for your interest in YouthBuild Inland Empire.This application will help us determine your motivation to join the program and what you hope to accomplish while in the program. We also need information to help you receive additional services. Please complete each item. If it does not apply to you write N/A in the space. Blank or incomplete applications will not be accepted. All information is confidential.

Notice: Once you have completed the application please check the email you provided. You will receive a link to submit 4 douments (ID, Birth Certificate, Proof of Address, Immunization record). You MUST complete the next step within 30 days. *If you do not have all 4 documents please contact the school you can still be eligible for enrollment.

Once you have completed this online application you must submit the above documents 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.

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 *

First Name Last Name
Effective Date *

Month Day Year
Date
Student's Signature *

Clear
Date *

Month Day Year
Date
Parent/Guardian's Signature (if student is under 18) *

Clear
Date *

Month Day Year
Date

Local Educational Agency Name Housing Questionnaire

California Department of Education

The form should be included with registration materials that the local educational agency (LEA) shares with families
Name *

First Name Middle Name Last Name
The information provided below will help the LEA determine what services you and 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 dur 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
The undersigned parent/guardian certifies that the information provided above is correct and accurate.
Parent/Guardian Name *
Signature *

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 childern may have the right to:

Immediate enrollment in the school they last attended (school of 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.

Countiune to attend their school of origin, if requested by you and it is in the best interest.

Receive transportation to and from school of origin, the same special programs and services, if needed as provided to all other children, including free meals and Title I.

Receive the full protections and services provided under all fedral and state laws, as it relates to homeless children, youth, and their families.
Please list all children currently living with you.
Name
M/F
Date of Birth

Month Day Year
Date
Grade
School
Name
M/F
Date of Birth

Month Day Year
Date
Grade
School
Name
M/F
Date of Birth

Month Day Year
Date
Grade
School

Informed Consent and Limits of Confidentiality

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 stadent 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:

Anyone working with a minor is required by law to:

Report any reasonable suspicion of child, elder, or dependent abuse to the appropriate county agency.

Notify an appropriate person and/or agency if the student indicates intent to physically harm him/herself or someone else.

If you have any questions or need further clarification please feel free to ask.
I, (Print Name) , hereby certify that I have read the above and understand that I may meet with an MSW intern for counseling services. *
Name
I, (Print Name), hereby certify that I understand the limitations of confidentiality and electronic communications. *
Name
Parent/Guardian's Signature *

Clear
Date *

Month Day Year
Date
Student Signature *

Clear
Date *

Month Day Year
Date

REQUEST FOR STUDENT RECORDS

Please fill out the following. If needed, YouthBuild Inland Empire may assist you requesting previous transcripts and/or IEP.
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Grade/ Last year attended *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Signature (parent signature if under 18) *

Clear

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, breastleeding/lactation status and rolated 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 beliof 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 resultin 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 anindividual makes a complaint or asks the school/office to take action. Complainants are protected from rotaliation 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

rcuevas@youthbuildcharter.org

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:

Training and work history

Current Employment status