504 N. Mountain View Ave Suite 200 San Bernardino Ca 92401 909-890-9106 Fax 909-890-0989 www.youthbuildinlandempire.org
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 in order to help you receive additional services. Please complete each item. If it doesn’t apply to you write N/A in the space.
Blank or incomplete applications will not be accepted. All information is confidential.
Where did you hear about YouthBuild?
why did you drop out?
Why are you interested in this program?
Training and work history
Have you ever been in another train program? YES NO If yes which ones?
Date attended Date attended
Did you complete the program? YES NO
Current Employment status
Are you employed? YES NO Full-time part-time Hours worked per week If unemployed, date most recent job ended Are you looking for work? YES NO Do you have a resume? YES NO Do you have children/dependents of your own? YES NO How many?Do they live with you? YES NO
Have you ever been arrested? YES NO Do you currently have a case pending? YES NO Have you ever been convicted of a misdemeanor? YES NO Have you ever been convicted of a felony? YES NO Have you ever been convicted of a crime? YES NO If yes, please describe and include dates and status of the case:
If yes, are you on probation/parole?YES
I attest that the information provided in the application is accurate and true and understand it is used to asset my interest and abilities to complete the program. YouthBuild Inland Empire does not share any of this information with outside agencies unless authorized by you. Furthermore, YBIE does not discriminate based on race, religion, sexual orientation, disability, or for any other reason.
Parent Name if under 18 years of age
Parent cell phone
Please tell us how you heard about YouthBuild Charter School.
YouthBuild Inland Empire 504 N. Mountain View Ave Suite 200 San Bernardino CA 92401 1-888-395-4408 www.youthbuildinlandempire.org
YouthBuild Charter School of California School Headquarters 155 West Washington Blvd., Suite 944 Los Angeles, CA 90015
O 213.741.2600 F 213.741.2628
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 National School Lunch Program (NSLP) Application 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 Prior School 1: Rcvd: Yes Rcvd: Yes Rcvd: Yes
Prior School 2:
Prior School 3:
(If more than 3 prior schools, please continue list on back of this form)
NOTE: 2019-20 Pre-Enrollment Application subject to Acceptance into a YouthBuild Program
YouthBuild Inland Empire 504 N. Mountain View Ave suite 200 San Bernardino CA 92401
Phone: 1-888-395-4408 Fax: 909-890-0989 Date:
Date of Birth
Is student’s physical address permanent - stable
Yes, I am in foster care or have been in foster care
if not, please check one of the following that best describes your situation: Development Center
Yes, I have been in a juvenile justice facility.
Yes, I have been incarcerated.
Note: Under the AB216, if you checked any of the above, you may be eligible to graduate by completing the minimum state requirements.Temporarily Doubled Up For eligibility determination, please see the academic counselorTemporary Sheltered for additional information.Unknown
Note: If you are homeless, you are eligible for AB1806.
Student’s Mailing Address:
Student Cell Phone
ETHNICITY SURVEY: *New federal race and ethnicity data collection/reporting requirements beginning in 2009-2010
Require all students to identify their ethnicity from the 2 choices below:
Is this student Hispanic or Latino?
No, not Hispanic or Latino
Race *No matter what ethnicity is selected above, at least one race must also be selected below: Please choose primary race and secondary race if applicable:
American Indian or Alaskan Native
Person having origins in any of the Black racial groups of Africa.
Middle Eastern A person having origins in any of the original Peoples of Europe (including South/Central Americans), the Middle East, or North Africa
a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including: Asian IndianJapanese Cambodian Korean Chinese Laotian Filipino Vietnamese Hmong Other Asian
Dominican Mexican Nicaraguan Salvadoran Other:
Islander having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Guamanian Hawaiian Samoan Tahitian Other Pacific Islander
How many credits has student completed?
Has student been enrolled in ANY school since August 2014
List all previous High School(s) Attended (most recent first): If attended more than 3 please continue list on separate sheet.
Name of High School
Last Year Attended
2 Name of High School (if applicable)
3 Name of High School (if applicable)
Date STUDENT first enrolled in school in the U.S.: Date STUDENT first enrolled in the California School System: Student Initial 9 Grade entry year:
(example 9/1/1999) (example 9/1/1999) (example: 2009-2010)
PARENTAL/GUARDIAN CONTACT INFORMATION: Is the parent/guardian on Active Duty Military? ☐ Yes ☐ No
If yes, which branch?
Lives with student? Yes / No
Is the parent/guardian on Active Duty Military? ☐ Yes ☐ No If yes, which branch?
The California Education Code requires all schools collect information about students and submit this information to the State. The required information includes home language, ethnicity, family income, and parent education level. Thank you for filling out the following four surveys.
Please check the box that describes the education level of your parent(s) or guardian(s):
Graduate Degree – MA, MA, PhD or EdD College Graduate – BA or BS Some College – AA or 2 full years at a 4 year university High School Graduate – Diploma, GED, or HS Equivalency Not a High School Graduate Declined to State
1. What language did this student first learn to speak?
2. What language does this student most frequently use at home?
3. In what language does the parent/guardian most frequently speak to the student?
4. What language is most often spoken by the adults in the home?
5. Is this student fluent in the English language (speaking, reading, writing)?
6. Has this student ever been enrolled in a Bilingual Program?
California Department of Education, February 2017
School Year 2019–20 YouthBuild Charter School of California – Site: SAN BERNARDINO (INLAND EMPIRE) Application for Free and Reduced-Price Meals Complete one
application per household. Please read the instructions on how to apply. Print clearly with a pen. This institution is an equal opportunity provider.
California Education Code Section 49557(a): Applications for free and reduced-price meals may be submitted at any time during a school day. Children participating in the federal National School Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by any other means.
Children in Foster Care and children who meet the definition of Homeless, Migrant, or Runaway are eligible for free meals.
Print the name of EACH STUDENT (First, Middle Initial, Last)
Enter school name and
Enter student’s birthdate
Check the applicable box if the student is foster, homeless, migrant, or runaway.
YouthBuild Inland Empire
Do ANY household members (child or adult) currently participate in CalFresh, CalWORKs or FDPIR? If NO, skip STEP 2 and continue to STEP 3.
If YES, check the applicable program box, enter one case number, skip STEP 3, and continue to STEP 4.
Certification: I certify (promise) that all information on this application is true and that all income is reported. I understand
CalFresh CalWORKs FDPIR
STEP 3 – REPORT INCOME FOR ALL HOUSEHOLD MEMBERS (Skip this step if you answered ‘YES’ in STEP 2)
that this information is given in connection with the receipt of federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information,
A. STUDENT INCOME: Sometimes students in the household earn income. Enter the TOTAL GROSS income (before deductions) in whole dollars earned by all students listed in STEP 1. Enter the appropriate pay period in the “How
Total Student Income
my children may lose meal benefits, and I may be prosecuted under applicable state and federal laws.
Often” box: W = Weekly, 2W = Biweekly, 2M = Twice a Month, M = Monthly, Y = Yearly
Signature of adult completing this application:
B. ALL OTHER HOUSEHOLD MEMBERS (including yourself): List ALL household members not listed in STEP 1, even if they do not receive income. For each household member, report the TOTAL GROSS income (before deductions) in whole dollars for each source. If the household member does not receive income from any sources, write “0”. If you enter “0” or leave any fields blank, you are certifying (promising) that there is no income to report.
Enter the appropriate pay period in the “How Often” box: W = Weekly, 2W = Biweekly, 2M = Twice a Month, M = Monthly, Y = Yearly
Print the name of ALL OTHER Household Members (First and Last)
Public Assistance/SSI/ Child Support/Alimony
Pensions/Retirement/ All Other Income
Earnings from Work
C. Total Household Members
D. Enter the last four digits of Social Security number (SSN) from the Primary Wage Earner or Other Adult Household Member
Check the box if
(Children and Adults)
DO NOT COMPLETE. SCHOOL USE ONLY
How Often? Weekly Bi-Weekly Twice a Month Monthly Yearly Annual Income Conversion: Weekly x52, Biweekly x26, Twice a Month x24, Monthly x12
Total Household Income
Total Household Size
Eligibility Status: Free Reduced-price Paid (Denied)
We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced-price meals.
Verified as: Homeless Migrant Runaway
Ethnicity (check one):
Hispanic or Latino
Not Hispanic or Latino
Race (check one or more):
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White
Who should I include in “Household Size”?
You must include yourself and all people living in your household, related or not (for example, children, grandparents, other relatives, or friends) who share income and expenses. If you live with other people who are economically independent (for example, who do not share income with your children, and who pay a pro-rated share of expenses), do not include them.
How do I report household income for pay received on a monthly, twice per month, b-weekly, and weekly basis?
For additional information on Household Size and Gross Household Income, please see the Eligibility Manual for School Meals on the U.S. Department of Agriculture Guidance and Resource Web page at http://www.fns.usda.gov/cnd/guidance/default.htm.
CA Dept. of Education Reviewed 25-March-2015
Parents/guardian grants their student permission to sign themselves in and out of the School Student is allowed to use computers at school
Yes Yes Yes Yes Parent/guardian grants permission to use student work produced by student for school purposes Yes
Parent/guardian grants permission to use student audio/video for school purposes Parent/guardian grants permission to use pictures of this student for school purposes
No No No No No
Special Education Services/504 Plan For students ages 16 through 22 years:
1. Has this student ever been in a Special Education Program?
2. Was this student in a Special Education Program at the last school attended?
3. Does this student have an active IEP (Individualized Education Program)? 4. Has this student ever been part of a 504 Plan?
For students over age 22:
5. Has this student ever been part of a 504 Plan?
IF NO: Sign and date here:
I certify my student has never received Special Education Services of any kind. I further certify my student does not have a 504 Plan. Parent/Guardian: XDate:
Adult Student 18 years of age and over: I certify that have never received Special Education Services of any kind. I further certify I do not have a 504 Plan. Adult Student: XDate:
IF YES: Sign here and provide a copy of the IEP, including an exit IEP.
I understand I must submit all Special Education Documentation and/or 504 Plan with my child’s Enrollment paperwork, and that without it my child cannot be enrolled with this Charter School. I certify that all statements are true and correct to the best of my knowledge. Parent/Guardian: XDate:
Adult Student 18 years of age and over I understand I must submit all Special Education Documentation and/or 504 Plan with my Enrollment paperwork and that without it I cannot enroll with this Charter School. I certify that all statements are true and correct to the best of my knowledge. Adult Student: XDate:
Is parent/guardian employed in one or more agricultural or fishing activities on a seasonal or other temporary basis? Yes No IF YES, Migration Number:
Has student taken a standardized test and been identified as gifted? Yes
I certify that all of the statements and information given above are true and correct to the best of my knowledge:
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)
Parent/Guardian’s Signature (if student is under 18)
YCSC Administrator’s Signature
For students 18 and older ONLY
Date of Birth:
I give permission to YouthBuild Charter School to release my student information to the individuals listed below. This may include attendance records, grade reports, discipline reports and any other information that pertains to my progress.
Name of individual
I am the person named above and am 18 years of age or older.
Date of Birth
Parent/Guardian #1 (and relationship—for example: mother, grandfather, etc
Parent/Guardian #2 (and relationship—for example: father, foster parent, etc
*Is there a custody issue regarding this student? Yes No
*Legal restrictions for any parent are as follows:
Court Order on file at school: Yes No
Please list two (2) neighbors/friends or nearby relatives who will assume temporary care of your child if you cannot be reached:
Relative/Friend (and relationship—for example: aunt, neighbor, etc
Please list all prescription medications taken by student at home. Please check any of the following that apply to your student:
VISION: Known eye condition/defect in vision Wears Glasses Wears Contact Lenses Glasses to be worn at all times HEARING: Known hearing problem Wears hearing Aid Preferential seating Student has a condition which may result in classroom emergency such as: Asthma Peanut Allergy Bee Sting Allergy Epilepsy Diabetes Heart Condition Seizures Other Please describe Other Health Condition:
What action is to be taken if your student has a complication due to his/her allergic condition or health condition? Please be specific
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.
Family Doctor/Local Medical Center
Insurance ID or Policy # 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.
Health Insurance Carrier:
Parent/Guardian Signature (if student is under 18)
Member Acceptance Letter – Referral to YouthBuild Charter School of CA
YouthBuild Charter School of California 155 W. Washington Blvd. Suite 517 Los Angeles, Ca 90015
Youth Power Community Solutions YouthBuild Inland Empire 504 N. Mountain View Ave. Suite 200 San Bernardino CA 92401 1-888-395-4408
The above referenced program participant has successfully fulfilled the initial requirements to be accepted as a member of YouthBuild Inland Empire. They request to enroll in YouthBuild Charter School of CA YouthBuild Inlands Empire Site.
Your assistance in this process is greatly appreciated.
Staff Name Requesting