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:

• 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.
• Continue to attend their school of origin, if requested by you and it is in the best interest.
• Receive transformation 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.

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.

Please answer ONE of the following (either monthly or annual income)

I certify that all of the statements and information given in this application above are true and correct to the best of my knowledge.

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.

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.

YCSC Student Required Technology Use Contract

Access to technology at Youthbuild Charter School of California (YCSC) is a privilege granted to students. Responsible users are permitted to utilize school-provided equipment, including laptops, iPads, and hotspots for internet connectivity, to fulfill educational assignments and projects as directed by their instructors. I am being given the privilege to use a YCSC-owned supervised electronic device. I agree to keep it safe and well maintained. I will follow the device guidelines explained below:

USAGE:

• To facilitate tracking, each piece of equipment is individually numbered. Students will be provided with a specific numbered device for their use.
• Unless a teacher provides different instructions, devices are to remain muted during virtual meetings and while in the classroom.
• Students are responsible for checking that their assigned technology is in good working order at the beginning of each class/session. Any issues must be reported to the teacher immediately to ensure the device is submitted for repair with the correct documentation.
• It is prohibited to send or view any material that is illegal, harassing, racially offensive, threatening, sexually explicit, profane, obscene, abusive, or defamatory. Because content is monitored, any violation will result in the device being locked instantly.
• Utilizing technology as a means to engage in cheating is strictly forbidden.
• Technology must be used exclusively for educational objectives.
• Students must not alter the function or appearance of any electronic device. This includes, but is not limited to, changing configurations, copying files, setting passwords, or installing software. All devices must remain in the configuration set by staff or the original factory settings.

RESPONSIBILITY:

• I acknowledge that the school's administration, teachers, or staff may inspect my assigned device at any time and without prior notification. Furthermore, I recognize that YouthBuild Charter School of California retains full ownership of the device.
• Any theft of or damage to school-owned property or technology is my responsibility.
• My assigned device will never be left without supervision.
• I will not permit anyone else to use or borrow my assigned device.
• I am aware that security software is active on the device to monitor its usage & location.
• The individual to whom the device was issued may be liable for its replacement cost.

CARE:

• I will protect the screen from scratches.
• I will keep food and beverages away from my assigned device.
• I will not mark, draw, write or place stickers on the device or case.
• I will not disassemble or attempt any repairs on any part of my assigned device.

CONSEQUENCES OF NOT FOLLOWING THE TECHNOLOGY CONTRACT:

• 1st offense: Restorative Assignment (Reflection, responsible use dialogue, etc.)
• 2nd offense: Restorative Meeting (Responsible use documentation)
• 3rd offense: Limited use restorative circle (Determine next steps up to termination of technology use)
• School staff reserve the right to enact more consequences as needed

***Until the devices are returned, items such as transcripts and diplomas may be delayed***

Complete the section below to acknowledge that you have read and understood everything above.

California Graduation Exemption Laws: AB 167/216, AB 1806, AB 2121

Students who believe they are eligible for any of the below credit exemptions 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 purposes of AB 167/216, youth involved in the juvenile justice system 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 to extend the same rights to those experiencing homelessness and transferred to a new school after completing their 2nd year 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 167/216

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

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

Other criteria factored in:

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

Information on AB2121

AB 2121 extends the credit exemption to any student who is a migratory child, as defined in subdivision (a) of Section 54441, who transfers between schools any time after the completion of the pupil’s second year of high school, and any newcomer pupil who also is in their third or fourth year of high school.

Other criteria factored in:

• Student is a migratory child (as defined in 20 US Code Section 7011) or a newcomer pupil ( as defined in Section 7011(5) of Title 20 of the United States Code (EC Section 51225.2[a][3])). Newcomer pupils are individuals who were not born in any state (each of the 50 states, the District of Columbia, and the Commonwealth of Puerto Rico); and (c) have not been attending one or more schools in the United States for more than three full academic years.
• Student transferred high schools after their 2nd year or is in their 3 rd or 4 th year of high school.

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
2202 S Figueroa St., #728
Los Angeles, CA 90007
213.741.2600
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.