Step Up: New Student Application    
This application is for prospective students interested in becoming apart of the 2021-22 Step Up cohort.

If you have any questions about this application please contact the Student Success Specialist, Site Supervisor, and/or Advocate who has been in contact with you during the enrollment process at your specific high school.
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Statement of Confidentiality:
It is the policy of all Open School programs that all information received regarding an applicant's application for admission will be treated with complete confidentiality. Only authorized Step Up school personnel have access to such information and then only to the extent that the information is relevant to admission and placement decisions. Information received within the scope of this policy is not disclosed to the applicant or the applicant's family.
Notice of Non-Discriminatory Policy:
Open School programs do not discriminate against any person with respect to employment or provision of services on the basis of race, color, national and ethnic origin, gender, sexual orientation, age, religion, class, marital status, political affiliation, disability, veteran status or any other category prograted by applicable law. Open School does not discriminate on these bases in the administration of any activities.
Student Information Section:
Enrolled High School *
Grade Level *
Student's First and Last Name *
Student's preferred name and/or nickname? (What we'll call you when referring to you.)
PPS ID:
Date of Birth: *
MM
/
DD
/
YYYY
Student Demographics Section:
The following questions help us to better serve your students and assess who is applying to our program.
Gender: *
Required
Pronouns: *
Required
Race and Ethnicity *
Required
Student's Cell:
Main Home Phone: *
Student's Email:
What is the best way for our staff to communicate with you? *
Required
Student's Current Residence Section:
Who does the student live with? *
Relationship(s) to student: *
Address: *
City: *
Zip Code: *
Parent/Guardian Section:
Name of Parent/Guardian *
Relationship to student: *
Address (feel free to state "Same as student"): *
City: *
Zip Code: *
Cell/Main Phone: *
2nd Phone:
Work Phone:
Parent/Guardian Email Address:
What is the best way for our staff to communicate with you? *
Required
What is the best week day for our staff to reach you? *
When is the best time of day for our staff to reach you? *
Additional Parent/Guardian Information Section:
(if applicable)
Parent/Guardian Name:
Relationship to student:
Address:
City:
Zip Code:
Main Phone:
2nd Phone:
Work Phone:
Emergency Contact Information Section:
Name of Emergency Contact: *
Relationship to student: *
Main phone: *
2nd Phone:
Student Information Continued:
Middle/K-8 School: *
How could Step Up best help? *
Required
Has your student been assessed as eligible for Special Education Services? *
Is your student eligible for Free/Reduced Lunch? *
Communications Section:
Language(s) Section:
Which language does the student use most often? *
What is the student's first language? *
Which language is spoken at home most often? *
Which language would you prefer our staff to use when communicating with you? *
Important Family Questionnaire
Some Step Up activities may pose a challenge to our youth and have the potential to generate an intense response. Therefore, the more information provided regarding your child's ability to cope with stress, the better our ability to care for them and keep them safe. For this reason, we ask that you volunteer some or all of the following information.
In the recent past, our family has dealt with:
My child/student has experienced significant social/emotional, mental health, or psychological challenges:
Clear selection
If you answered "Yes" to the last question, please describe:
My child has been hospitalized within the last two years for a psychiatric and/or mental health concern:
Clear selection
If you answered "Yes" to the last question, please describe:
Students are sometimes asked to read handouts or write in their journals/reflection papers. To minimize stress for students and for students who struggle with learning disabilities, please let us know if your child requires accommodations in reading and/or writing.
Clear selection
If you answered "Yes" to the last question, please describe:
My child gets along with other youth: *
Our family is houseless or experiencing housing issues: *
If you answered "Yes" to the last question, please describe:
May we contact you regarding the information you provided should we have any additional questions? *
Provide the following information ONLY if applicable:
Mentor info, CSD caregiver, Juvenile Court counselor, other
Mentor Name:
Mentor's Agency:
Mentor's Phone Number:
CSD Caregiver Name:
CSD Caregiver Phone Number:
Juvenile Court Counselor Name:
Juvenile Court Counselor Phone Number:
Other Counselor Name:
Other Counselor's Agency:
Other Counselor's Phone Number:
Electronic Signature Consent Statement
This statement refers to the following: "Authorization to Provide Treatment"; "Field Trip Permission Form"; "Release of Student Information"; "Electronic Image/Photo Release Statement"

By checking below, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature.
Electronic Signature Consent Agreement: *
Required
Medical Information
Information collected in this document is to ensure we are equipped to handle any incident that may occur while your child is under Step Up supervision. Please use your discretion in completing this form.
Allergies: Please identify any allergies to foods, drugs, insect bites, dust, etc., and give the nature of the reaction(s): *
Medications: Please list any medications that will need to be taken during Leadership Camp, Field Trips, etc. (include medication name, dosage, frequency, and whether or not the student needs assistance in administering said medication): *
Injuries and/or Disabilities: Describe any disabilities, such as injuries, surgery, broken bones and/or sprains which might limit participation during certain activities. *
Communicable Diseases: Please list any known infections and/or diseases which are transmissible directly from one person to another (if any):
Common Conditions: Please check all that apply: *
Required
If you checked the box "Special dietary needs" please provide more details:
Please list any other medical conditions not listed above:
Medical Treatment
In the event of an injury the Step Up Program of Open School Inc. will make every effort to contact the parent/guardian prior to treatment. In a situation in which effort to make contact with the parent/guardian is unsuccessful, treatment for the injury will be pursued.
Authorization to Provide Treatment
As a parent/legal guardian of my student, I authorize Open School staff to assume care and responsibility of my child while on field trips associated with Open School and during the course of the Open School program. This authorization is applicable throughout my child's involvement with the Step Up program.

I hereby grant authority for my student to receive emergency treatment/care of a legally qualified doctor, dentist, and/or hospital when it is deemed necessary or in my students' best interest.

In the event that emergency medication is needed, i.e. Epi Pen, inhaler, or other prescription medications, Open School staff has permission to transport my child to the nearest licensed medical professional to administer medication as directed, unless I provide specific permission (see below)*

I hereby release Open School from any responsibility for any expenses which may be incurred in providing emergency, dental, or medical treatment.
Do you agree to the above "Authorization to Provide Treatment"? *
Required
Permission to Administer Specific Medication
In the case of an emergency in which your child cannot be transported to the nearest licensed medical professional in a timely fashion, you may give consent to an Open School staff member to administer the specific form of medication below by checking the appropriate box and agreeing to this release.
I consent to an Open School Staff member to administer the specific form of medication below to my student: *
Please provide an electronic signature by typing out your name as the legal parent/guardian of the applicant: *
Field Trip Permission Form
Please read through this entire section, if there is anything about this section or the described activities that you do not understand please let us know. Read carefully and make sure you understand each detail before signing.
It is the practice of Open School programs to keep students and parents/guardians safe during educational experiences. In travelling off school property, additional opportunities are offered only if parents/guardians agree their child may participate despite potential increased risk.
- The dangers which are present in these trips are those commonly experienced by and known to all persons traveling with young people within the United States. Open School cannot and does not claim to control such dangers. Parents and participants wishing more information regarding the trip and its leadership should contact the Program Director.

- Parents are responsible for determining whether their student has the ability to participate based on behavior and maturity level, given all information provided. Students must have the ability to accept direction and participate responsibly and safely.

- Field trips are a part of the program and may occur with little or no advance notice. In some cases, transportation for field trips may be provided by a staff member trained and certified to provide transportation in an Open School vehicle or common carrier.

- Off-site activities such as overnight camps, challenge, or ropes courses, include known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to participants. Such risks cannot be eliminated without jeopardizing the essential qualities of the activity. The risks include, among other things: the hazards of traversing uneven terrain and slips and falls; the use of climbing ropes and equipment; the risks of exposure to insect bites; a student’s physical condition, and the physical exertion associated with this activity.
Field Trip Permission Statement
I hereby release and agree to defend and hold harmless Open School Inc, its officers, agents, and employees, including the Program Director and their assigns, from any claims by any person, entity or estate, in any forum that may arise against them by reason of property loss or injury and/or death resulting from any cause including, but not limited to, the student or other students having failed to properly carry out instructions from Open School employees.

I give permission for my student to participate in field trips organized by the Step Up Program of Open School Inc. for the duration of time that they are enrolled in Step Up.

I acknowledge I have the authority to agree to and grant this release.
Do you agree to the above "Field Trip Permission Statement"? *
Please provide an electronic signature by typing out your name as the legal parent/guardian of the applicant: *
Release of Student Information & Photo Release Section:
Release of Student Information Statement
As the Parent/Guardian of the student that I am applying for, I authorize the release and exchange of my students’ school-related information between any and all public or private school districts (incl PPS), the Open School Step Up Program, all Step Up Program partners, and Open School’s independent evaluators (RMC Research Corporation.)

The information provided is to be treated as confidential and only used to support the educational needs of my student, and for program evaluation. Information sought will include any and all academic and attendance information, needs or other tags/indicators, discipline data, family demographic data and Individualized Education Plans (IEP) where relevant.

I hereby approve the release and sharing of information as indicated above for the duration of my child’s involvement with Open School Step Up program and one year beyond high school graduation (up to five years total) to allow for long term evaluation of program effectiveness.

I understand that I may rescind or cancel this release of information at any time by contacting the Step Up Program Site Supervisor at my child’s high school and/or by calling the Open School Step Up office at (503) 951-8069.
Do you agree with the above "Release of Student Information Statement"? *
Please provide an electronic signature by typing out your name as the legal parent/guardian of the applicant: *
Electronic Image/Photo Release Statement
I agree to allow Step Up and/or Open School to use electronic images, video footage or photographs of my student in Step Up and/or Open School literature, demonstrations, outreach materials, website, social media outlets, and/or brochures that may be distributed to the general public and businesses for educational and/or informational purposes.

Additionally, I agree that my student's name may be used in various media publications as the publication relates to my child’s participation in Open School programs. This could include but is not limited to press conferences, educational conferences, newspaper articles and radio or television interviews.
Please select one in accordance with the above "Electronic Image/Photo Release Statement": *
Please provide an electronic signature by typing out your name as the legal parent/guardian of the applicant: *
Thank you!
Please read below for the next steps:

Once your student's application has been submitted in the coming weeks the Student Success Specialist, Site Supervisor, and/or Advocate who has been in contact with you during the enrollment process at your specific high school will be in touch with you.

If your student is not enrolled into our program it is likely that they may be placed on a waitlist, if that is the case we will do our best to update you and your student.

If at anytime you would like to withdraw your student's application to our program for any reason, please let us know!
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