Youth Initiative High School Day Student Enrollment Application - Parent
YIHS admits students of any race, color, religion (creed), gender, gender expression, national origin (ancestry), sexual orientation, or parental status to all the rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of any race, color, religion (creed), gender, gender expression, national origin (ancestry), sexual orientation, or parental status in administration of its educational policies, admissions policies, scholarship and loan programs, athletic or other school-administered programs.
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Student Last Name *
Student First Name *
Household X Information
(X) Household Physical Address *
(X) Household Mailing Address *
(X) Is this a primary residence of the student? *
(X) Parent 1 Name *
(X) Parent 2 Name *
(X) Additional household members / ages / and relationship to applicant *
(X) Home Phone *
(X) Work Phone *
(X) Cell Phone *
(X) Other Phone (Please Indicate) *
(X) Parent Email(s) *
(X) Please indicate what, if any, information you would like withheld from school directories accessible by other students, parents, and faculty
Household Y Information
(Y) Household Physical Address *
(Y) Household Mailing Address *
(Y) Is this a primary residence of the student? *
(Y) Parent 1 Name
(Y) Parent 2 Name
(Y) Additional household members / ages / and relationship to applicant
(Y) Home Phone
(Y) Work Phone
(Y) Cell Phone
(Y) Other Phone (Please Indicate)
(Y) Parent Email(s)
(Y) Please indicate what, if any, information you would like withheld from school directories accessible by other students, parents, and faculty
Please write the names of ALL individuals who should receive academic information and updates for this student: *
If someone's name is NOT listed, they will NOT receive academic or otherupdates about this student
What is your child’s academic life like? Include what you consider to be strong points and weak points? *
Please describe your student’s social life. *
Has your child had educational testing? If yes, please describe. *
Does your child have any learning, behavioral, or emotional difficulties? Please describe. *
Please describe any serious illnesses or traumas your child has had. *
Has your child ever undergone psychiatric therapy or psychological counseling? Please describe. *
To your knowledge, has your child used alcohol, nicotine, marijuana, or other drugs? Please explain. *
Please share any other biographical information that may help us to understand and serve your child. *
Health and Medical Information
Local Emergency Contact Name *
This person should NOT be a member of your household.  This person SHOULD be locally available to assist student in an emergent situation.
Local Emergency Contact Home Phone Number *
Local Emergency Contact Cell/Work Phone Number *
Local Emergency Contact Relationship to Applicant *
Health Care Provider Clinic Name *
Health Care Provider Primary Care Provider *
Health Care Provider Address *
Health Care Provider Phone *
Please list all medications or supplements your student takes on a daily or regular basis. *
Please list all allergies this student has. *
Please list all allergies this student has.  Please indicate if this student carries an EpiPen. *
Has your child ever had seizures or loss of consciousness?  Please describe. *
Please indicate any medications your child CAN be given in case of a minor injury or headache *
Required
Does your child have any other health or medical conditions we should be aware of? *
Parent Signature *
By typing my full legal name below I hereby give permission for my son/daughter to participate in field trips and off-campus school related activities. I hereby give my consent for emergency medical care or treatment if I cannot be reached. I hereby give consent to YIHS to use my student’s likeness or schoolwork in promotional materials. I commit to work with the Faculty and Administration of the school to assist my student in meeting his/her commitment to respect and abide by the school’s policies and guidelines described in the Vision and Purpose Statement of the YIHS.
Parent Signature Date *
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Parent Signatory Birth Date *
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