Application

Please note that the information obtained in this application is kept confidential and is shared only with YouthBuild Staff. Information is complied for state reporting purposes. You are to answer all questions on this application. If you do not fully complete the application it will result in a delay in the processing of your application. This will delay your enrollment into YouthBuild Columbus Community School. If the question does not apply to you place N/A in the appropriate box.

Contact Information

Please complete the following information in order that we may contact you. Contacts could include mother, father, sister, brother, grandmother, grandfather or other relatives. You must provide at least two (2) contacts.

Contact 1

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Relationship *

Contact 3

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Relationship *

Contact 2

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Relationship *

Contact 4

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Relationship *

Education

Please list the last three high schools you have attended and dates beginning with the most recent:

Ohio Graduation Tests

Medical History

Personal Interest

Family Information

Please provide the following information regarding your child or children. If you do not have any children, please skip this section.

What are their names, ages, and relationship to you?

Name *

First

Last

Age *

Relationship to you *

Name *

First

Last

Age *

Relationship to you *

Name *

First

Last

Age *

Relationship to you *

Name *

First

Last

Age *

Relationship to you *

Name *

First

Last

Age *

Relationship to you *

Name *

First

Last

Age *

Relationship to you *

Are you or anyone in your household current receiving any of the following services? AFDC/TANK, General Assistance, SSI, Food Stamps, WIC, Public Housing/Section 8, Other Public Assistance, Unemployment Compensation, or Earnings from Work *

Yes No

Criminal Justice System

If you answered yes to being on supervised probation or parole, you are to provide the names and telephone numbers of your probation/parole officer(s):

Before click the submit button, please be sure that all of your information is complete and accurate. You will still need to provide the school with the appropriate enrollment documents as outlined on the enrollment page. You will also need to fill out the request for records document and the free and reduced lunch document, which can be downloaded and printed on the enrollment page.

By clicking this submit button, you are acknowledging that the information included in this application is complete and accurate. Your information will not be shared or sold to anyone outside of YouthBuild Columbus Community School. YouthBuild Columbus Community School holds high standards for privacy when it comes to student information. If you have any questions or concerns, please contact the school at (614) 291-0805.

2012 - 2013 Application

Contact Information

Education

Ohio Graduation Tests

Medical History

Personal Interest

Family Information