Application for VIBE Flexible Learning Programs

1
We are no longer accepting applications for high school students for the 2024-2025 school year.

Please check back soon for applications for next school year.
2
Has this student been in VIBE before?* This field is required.
Yes, my student is already enrolled in VIBE.
Yes, my student was previously enrolled in VIBE, but is not currently.
No, this is my student's first time applying for VIBE.
3
Please choose which VIBE option your student would like:* This field is required.
VIBE Flex (part virtual, part in person @ BHS)
VIBE Virtual (fully virtual)
4
Name* This field is required.
First Name
Middle Name
Last Name
5
Gender* This field is required.
Please Select
Please Select
Male
Female
Prefer not to answer
6
Student Birthdate* This field is required.
Date
Month
Day
Year
7
Grade of student for the 2024-2025 school year.* This field is required.
9
10
11
12
8
District student is currently enrolled in.* This field is required.
Burlington
Fort Madison
Keokuk
Other
9
What district is the student currently enrolled in?* This field is required.
10
Does this student have an IEP (Do they receive Special Education instruction through an Individualized Education Plan)* This field is required.
Yes - IEP
No IEP
I am not sure.
11
Important Information: We will review your child's IEP to determine if VIBE is able to meet the needs of your student. An intake meeting with the IEP team will take place before starting at VIBE.
12
Is the student Hispanic/Latino?
Yes
No
13
What is the race of the student? (Select one or more)
White
Black
Asian
American Indian/Alaskan Native
Hispanic/Latino
Native Hawaiian Pacific Islander
14
Primary Guardian 1* This field is required.
First Name
Last Name
15
What is Guardian 1's relationship with the student?
Mother
Father
Grandmother
Grandfather
Aunt
Uncle
Other
16
Guardian 1 Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Does the student live at this address?* This field is required.
Yes
No
18
What kind of phone(s) does Guardian 1 have? Check all that apply.* This field is required.
Home phone/landline
Cell phone
Work phone
19
Guardian 1 Home Phone/Landline Number* This field is required.
xxx-xxx-xxxx
20
Guardian 1 Cell Phone Number* This field is required.
xxx-xxx-xxxx
21
Guardian 1 Work Phone Number* This field is required.
xxx-xxx-xxxx
22
Guardian 1 Email* This field is required.
example@example.com
23
Would you like to add a 2nd guardian?* This field is required.
Yes
No
24
Primary Guardian 2
First Name
Last Name
25
What is Guardian 2's relationship with the student?
Mother
Father
Grandmother
Grandfather
Aunt
Uncle
Other
26
Does Guardian 2 live at the same address as Guardian 1?
Yes
No
27
Guardian 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
28
What kind of phone(s) does Guardian 2 have? Check all that apply.
Home phone/landline
Cell phone
Work phone
29
Guardian 2 Home Phone/Landline Number
xxx-xxx-xxxx
30
Guardian 2 Cell Phone Number
xxx-xxx-xxxx
31
Guardian 2 Work Number
xxx-xxx-xxxx
32
Guardian 2 Email
example@example.com
33
Where will the student be during most school days?* This field is required.
At the home address listed above
Somewhere other than the address listed above
34
Describe where the student will be on school days. Please list any adults who will be with the student during the day.
35
Student's Cell Phone Number (if applicable)
36
What is this student's greatest challenge in school?* This field is required.
37
Why is VIBE the best educational option for your child at this time?* This field is required.
38
Is there anything else you would like us to know about your child or situation?* This field is required.
39
FIELD TRIP PERMISSION

I understand that as part of the educational process, BCSD students may be transported by bus or other means to attend educationally related field trips. Prior to any trip, you will be notified of the date and destination. If you wish to exclude your child from that particular trip, you may do so by notifying the school.

By choosing 'yes', I consent for my student to be transported in a school bus or other district approved vehicle to attend field class or school field trips.
40
Do you give field trip permissions?* This field is required.
Please Select
Please Select
Yes
No
41
PICTURE/VIDEO PARENTAL PERMISSION

I understand that pictures/video may be taken of my child involving school and classroom activities.

By choosing 'yes', I provide my consent for my student to be involved and understand that the photos could be used in the local newspaper or other publication or media during his/her school year.
42
Do you give picture/video permission?* This field is required.
Please Select
Please Select
Yes
No
43
Parent/Guardian Name* This field is required.
First Name
Last Name
44
Parent/Guardian Signature* This field is required.
Clear
Should be Empty:

We are no longer accepting applications for high school students for the 2024-2025 school year.

Please check back soon for applications for next school year.