Moreno Valley/RSBA: 2023-24 New Student Enrollment Application for Minors

Moreno Valley/ RSBA: 2023 – 2024 Enrollment Application for Minors

Please Note: You will need a parent/guardian to help fill out and sign this online form.
Dear Prospective Student,

Thank you for your interest in YouthBuild Charter School of California (YCSC). To consider your application, all of the following documents are required. Please return this checklist with your application and all documents for consideration. Incomplete applications will not be accepted.
- Signed Letter / Proof of Acceptance to local YouthBuild program
- Confirm student is NOT enrolled in two schools at the same time. PAR and/or Withdraw Slip from previous school with an exit date will be acceptable
- Completed Enrollment Application:
  - YCSC Enrollment Application
  - Student Agreement
  - Student Release Form
  - YouthBuild Emergency Card
- Household Income Data Collection Form
- Birth Certificate – COPY
- Identification card reflecting current address: Driver License or CA ID - COPY
- Utility Bill – COPY
- Proof of Household Income (e.g. Check stub, MediCal Lifeline or Public Benefit Award Letter, Tax Return or No Income Certification) - COPY
- Special Education Documents (IEP) and 504 Plan or Opt Out Letter – COPY
- Immunization Records - TDAP IS A REQUIREMENT (Minors Only)
- Official School Transcripts
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.

PREVIOUS SCHOOLING INFORMATION
How many credits has student completed? (Provide your best estimate if you aren't sure.)*
Has the student been enrolled in ANY school during THIS school year?*

Yes, student was enrolled at another school during THIS school year.No, student has not been enrolled at any school THIS school year.
List all previous high schools the student attended (most recent first). If you have not attended high school previously, please write N/A in the box for High School #1.
Name of Previous High School #1
City of High School #1
Last Year Student Attended High School #1
Name of Previous High School #2 (if applicable)
City of High School #2
Last Year Student Attended High School #2
Name of Previous High School #3 (if applicable)
City of High School #3
Last Year Student Attended High School #3
Check the box below if the student was born outside the U.S. and its territories and enrolled less than 3 cumulative years in the U.S.

Student was born outside the U.S. and its territories and has been enrolled for less than 3 cumulative years in the U.S.
What date did the student first enroll in school in the U.S.? (If unsure, please give your best estimate.)*

MonthDayYear
Date
What date did the student first enroll in the California School System? (If unsure, please give your best estimate.)*

MonthDayYear
Date
What school year did the student initially enter 9th grade? (Ex: 2019-2020)*

Parent/Guardian Contact Information
Name of Parent/Guardian #1*
Relationship to student (ex: mother, father, aunt, legal guardian)*
Does Parent/Guardian #1 live with the student? (Yes/ No)*
Home/Cell Phone of Parent/Guardian #1*
Work Number of Parent/Guardian #1 (if applicable)
Please enter a valid phone number.
Address of Parent/Guardian #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Parent/Guardian #1 on Active Duty Military?*

YesNo
If yes, which branch?
Name of Parent/Guardian #2
Relationship to student
Does Parent/Guardian #2 live with the student? (Yes/ No)
Home/Cell Phone of Parent/Guardian #2
Work Number of Parent/Guardian #2 (if applicable)
Address of Parent/Guardian #2

Street Address

Street Address Line 2

CityState / Province

Zip
Is Parent/Guardian #2 on Active Duty Military?

YesNo
If yes, which branch?

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

YesNo
Does the student have access to the Internet from home?*

YesNo
How many times has the student's family moved in the past 12 months?*

Special Education Services/ 504 Plan

This section must be completed with a parent/guardian.
1. Has this student ever been in a Special Education Program?*

YesNo
2. Was this student in a Special Education Program at the last school attended?*

YesNo
3. Does this student have an active IEP (Individualized Education Program)?*

YesNo
4. Has this student ever been part of a 504 Plan?*

YesNo
If you selected NO for all of the questions above, please sign below and proceed to the next page of the application. If you selected YES on any of the questions above, please do not sign below and instead review and sign in the next section.
Parent/Guardian Signature: I certify that my student has never received Special Education Services of any kind and that my student does not have a 504 Plan.

Clear
Date

MonthDayYear
Date
If you selected YES on any of the questions in the Special Education Survey above, please sign below and provide the counselor a copy of the IEP, including an exit IEP.
Parent/Guardian Signature: I understand that I must submit all Special Education Documentation and/or 504 Plan with my child's Enrollment Application and that without it, my child cannot be enrolled with YouthBuild Charter School of California. I certify that all statements are true and correct to the best of my knowledge.

Clear
Date

MonthDayYear
Date

Agriculture and Gifted/Talented Survey

This section must be completed by a parent/guardian.
Is the parent/guardian employed in one or more agricultural or fishing activities on a seasonal or other temporary basis (migrant worker)?*

YesNo
If YES, enter the Migration Number below:
Has your student ever taken a standardized test and been identified as gifted?*

YesNo
I (parent/guardian) certify that all of the statements and information given above and in the previous two sections are true and correct to the best of my knowledge:
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
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*

MonthDayYear
Date
Student's Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date

Emergency Information 2023-24
Student's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IN CASE OF EMERGENCY, PLEASE CONTACT:
Name of Parent/Guardian #1 and relationship (ex: mother, guardian, etc.)*
Ex: Jane Doe, Mother
Home/Cell Phone of Parent/Guardian #1*
Work Phone of Parent/Guardian #1
Name of Parent/Guardian #2 and relationship (ex: father, grandfather, etc.)
Ex: John Doe, Grandfather
Home/Cell Phone of Parent/Guardian #2
Work Phone of Parent/Guardian #2
Is there a custody issue regarding this student?*

YesNo
If you marked yes in the question above, list legal restrictions for either parent
If you marked yes in the question above, is there a court order on file at the school?

YesNo
Please list two (2) neighbors/friends or nearby relatives who will assume temporary care of your child if you cannot be reached
Name of Relative/Friend #1 and relationship (ex: neighbor, aunt, etc.)*
Ex: Jane Doe, Neighbor
Home/Cell Phone Number of Relative/Friend #1*
Please enter a valid phone number.
Work Phone Number of Relative/Friend #1
Please enter a valid phone number.
Name of Relative/Friend #2 and relationship (ex: grandmother, family friend, etc.)*
Ex: John Doe, Grandfather
Home/Cell Phone of Relative/Friend #2*
Work Phone of Relative/Friend #2

Local Educational Agency Name Housing Questionnaire

This form should be filled out by a parent/guardian.
Name*

First NameMiddle NameLast 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 Management Agency (FEMA) traillerSharing housing with other(s) due to loss of housing, economic hardship, natural disaster, lack of adequate housing, or similar reasonLiving 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 reasonLiving in a single-home residence that is permanentI am a student under the age of 18 and living apart from parent(s) or guardian
Parent/Guardian Name*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Phone Number*
Street Address*
City*
State*
Zip*
Your child or children 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 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 of the student.
- 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.
- Receive the full protections and services provided under all federal and state laws, as it relates to homeless children, youth, and their families.

Please list all children currently living with you.

	Name	M/F	Birthdate	Grade	School
Child 1
Child 2
Child 3

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@youthbuildcharter.org.

Informed Consent and Limits of Confidentiality
School Counseling Services

This letter is intended to inform and request your consent for your student to receive counseling services at our school site. As part of our structured and coherent counseling program, students may be referred to, or request, counseling services. These services are provided at no cost. However, these services are not intended as a substitute for diagnosis or treatment for any mental health disorder. The MSW interns along with a licensed clinician will provide assistance through case management, one-on-one counseling, crisis intervention, behavioral counseling, group counseling, 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 or your son/daughter, the school, and your family. The MSW interns at YCSC are available to address the wellness needs of all students. Your student may choose to visit the MSW interns to confidentially speak with them. During the process of providing these services all other information exchanged will be kept confidential.

Confidentiality

We have an ethical obligation to maintain student’s confidentiality to facilitate the appropriate support for your student in a school setting. Whenever possible and in the best interest of your student the MSW intern/counselor will encourage and seek permission from your student to share information and conversations with their parents/guardians. Exceptions to confidentiality exist to protect the emotional and physical safety of your student.

Exceptions to confidentiality in a school setting:
- If your student indicates they are engaging in self-harming behavior or if they are experiencing any suicide ideation that presents a risk to safety and wellbeing. (Legally mandated)
- If your student indicates that someone is harming them either emotionally, psychologically, or physically. (Legally mandated)
- If your student indicates that they are going to harm someone else. (Legally mandated)
- If your student is visibly under the influence of drugs or alcohol.
The MSW interns work on a team with school staff and YouthBuild affiliated partners. Therefore, they need to notify faculty/staff of the working relationship between the MSW intern and student. The information shared will include attendance and recommendations to enhance the student’s academic progress. No other specific information regarding sessions will be provided to the school/partner staff unless verbal/written consent is given by the student to do so.

Notice to Parent/Guardian regarding Consent

Pursuant to Family Code 6920-6926 and Health Code 124260, in certain situations, students 12 years or older may consent to counseling services on their own behalf. Including parent/guardian in a student’s services are a priority of YCSC. We recognize that in most cases, parent involvement yields greater outcomes for students and when appropriate the staff will strongly encourage parent involvement in services.

My signature below indicates that I have been notified about YouthBuild Charter School of California’s mental health counseling services, informed consent and the limits to confidentiality.
Type Parent/Guardian's Full Name
Parent/Guardian’s Signature*

Clear
Date*

MonthDayYear
Date
Type student's full name
Student's Signature*

Clear
Date*

MonthDayYear
Date
BBS Notice to Clients

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov , or by calling (916) 574-7830.

California Graduation Exemption Laws: AB 167/216 & AB 1806

Students/parents should reach out to the Counselor or Principal for more information

Overview of the Assembly Bill 167/216

AB167/216: (California Education Code §§51225.1 and 51225.2) applies to students in foster care or involved with the juvenile justice system and transfer to a new school after completing their 2nd year of high school.

Eligibility of the AB 167/216

AB 167/216: The student must be identified as a foster as defined below:
- Foster youth are considered subject to the Welfare and institutions code (WIC) sections 300 or 309 petitions.
- For the youth involved in the juvenile justice system for the purposes of AB 167/216, the student must be subject to a petition under WIC section 602. A student is considered a WIC 602 youth so long as they are charged with a crime in delinquency court; they do not need to be already found guilty or placed on probation.
Overview of the Assembly Bill 1806 & 490

AB 1806: Became effective on January 1, 2015 (California Education Code §§51225.1 and 51225.2). It extended the same rights to those experiencing homelessness and transferred to a new school after completing their 2nd year of high school.
- Such students are eligible to graduate under the California Department of Education (CDE) graduation requirements if the district determines they cannot reasonably complete the district graduation requirements within four years of high school.
AB 490: Allows schools to issue full or partial credit for coursework satisfactorily completed at a previous school.
- When Partial credit is awarded in a particular course, the student shall be enrolled in the same or equivalent course to enable the student to complete the entire course.
Eligibility of the Assembly Bill 1806 & 490

AB 1806 & AB 490: A student identified as homeless as defined below.

a.) The McKinney-Vento Act defines homeless children and youth as individuals who lack a fixed, regular, and adequate nighttime residence. This definition also includes Children and youth sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason.

b.) The student residency questionnaire provides more details on students who qualify as homeless and must be completed annually.

Other criteria factored in:

c.) A student with an open foster care/juvenile court case or identified as a homeless transfer.
d.) The student could not complete the additional district graduation requirements within 4 total years of high school enrollment.

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
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.
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Moreno Valley/ RSBA: 2023 – 2024 Enrollment Application for Minors

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

PREVIOUS SCHOOLING INFORMATION

Parent/Guardian Contact Information

Parent/Guardian Education Level Survey

HOME LANGUAGE SURVEY

Dashboard Alternative School Status (DASS)

APLUS+ Schools Home Survey

Household Income Data Collection

Parent/Guardian Release Survey

Special Education Services/ 504 Plan

Agriculture and Gifted/Talented Survey

Master Agreement

Emergency Information 2023-24

IN CASE OF EMERGENCY, PLEASE CONTACT:

Please list two (2) neighbors/friends or nearby relatives who will assume temporary care of your child if you cannot be reached

Health Information

Local Educational Agency Name Housing Questionnaire

Informed Consent and Limits of Confidentiality

NONDISCRIMINATION STATEMENT