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Annual Report
2012 - 2013 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.
*
Indicates required field
Today's Date
*
Last Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
First Name
*
Middle Name
*
Home Phone
*
Cell Phone
*
Email
*
Date of Birth
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Age
*
16
17
18
19
20
21
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
1990
1991
1992
1993
1994
1995
1996
1997
Are you currently or have you ever been on on an IEP?
*
Yes
No
Social Security Number
*
Birth City
*
Mother's Maiden Name
*
Sex
*
Male
Female
Ethnicity
*
Asian or Pacific Islander
Black, non-Hispanic
Hispanic
American Indian or Alaskan Native
Multiracial
Pacific Islander or Hawaiian Native
White, non-Hispanic
Primary Language
*
English
Spanish
Other
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
*
Which program are you interested in?
*
Construction
Nursing
How did you hear about us? Check all that apply.
*
Returning YB Student
Walk In
Radio
Newspaper
Friend
Website
Other
Education
Please list the last three high schools you have attended and dates beginning with the most recent:
High School Attended
*
High School Attended
*
High School Attended
*
City, State
*
City, State
*
City, State
*
Dates
*
Dates
*
Dates
*
What year did you begin 9th grade?
*
Have you ever been suspended from a high school?
*
Yes
No
Have you ever been expelled from a high school?
*
Yes
No
If Yes, what is the name of the school you were removed from?
*
If Yes, why were you removed?
*
If you dropped out, what grade?
*
8th or below
9th
10th
11th
12th
I did not drop out
What year did you drop out?
*
Type N/A if you did not drop out
If you dropped out, why did you not complete high school? (Check all that apply)
*
Pregnancy
Attendance
Legal Problems
Discipline Problems
Family Problems
Lack of Interest
Other
I did not drop out
Ohio Graduation Tests
Which of the following Ohio Graduation Tests have you taken? (Check all that apply)
*
Reading
Mathematics
Writing
Science
Social Studies
None
Which of the following Ohio Graduation Tests have you passed? (Check all that apply)
*
Reading
Mathematics
Writing
Science
Social Studies
None
At which school(s) did you take each test?
*
Type N/A if you have not taken any OGTs
Medical History
Do you have any medical conditions that would prevent you from performing on the construction site?
*
Yes
No
If yes, are you under a doctor's care?
*
Yes
No
Doctor's Name
*
List all medications that you are currently taking, please include dosage and how often.
*
Doctor's Phone Number
*
Personal Interest
Name three goals you would like to accomplish while studying at YouthBuild Columbus Community School.
*
Family Information
What is your marital status?
*
Single
Married
Divorced
Separated
Engaged
Never Married
Do you have any children?
*
Yes
No
If yes, how many?
*
Do you have a daycare provider?
*
Yes
No
Do you have Title XX?
*
Yes
No
Do you pay or receive child support?
*
Yes
No
If yes, how often do you pay or receive support?
*
Weekly
Biweekly
Monthly
Has the court issued child support orders?
*
Yes
No
Do you have a backup daycare provider?
*
Yes
No
Are you enrolled in LEAP?
*
Yes
No
Are you pregnant?
*
Yes
No
If yes, when are you due?
*
Please provide the following information regarding your child or children. If you do not have any children, please skip this section.
Name of Child
*
First
Last
Child's Date of Birth
*
Do you have custody of the child?
*
Yes
No
Does the child live with you?
*
Yes
No
Name of Child
*
First
Last
Child's Date of Birth
*
Do you have custody of the child?
*
Yes
No
Does the child live with you?
*
Yes
No
Name of Child
*
First
Last
Child's Date of Birth
*
Do you have custody of the child?
*
Yes
No
Does the child live with you?
*
Yes
No
Name of Child
*
First
Last
Child's Date of Birth
*
Do you have custody of the child?
*
Yes
No
Does the child live with you?
*
Yes
No
Including yourself, how many people live in your household?
*
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
Please list the services received, the monthly amount, and the household member receiving benefits
*
Criminal Justice System
Have you ever been convicted of a crime?
*
Yes
No
If yes, was the charge a misdemeanor or a felony?
*
Misdemeanor
Felony
What was the charge?
*
Are you being court ordered to attend school?
*
Yes
No
Were you charged as a juvenile?
*
Yes
No
What year was the charge?
*
Were you charged as an adult?
*
Yes
No
What year was the charge?
*
Do you have a pending case now?
*
Yes
No
What is the court date?
*
Are you on supervised probation or parole?
*
Yes
No
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):
Probation/Parole Officer's Name
*
First
Last
Phone Number
*
Probation/Parole Officer's Name
*
First
Last
Phone Number
*
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.
Submit
YouthBuild Columbus Community School does not discriminate on the basis of race, religion, gender, nationality, age disability or ethnic background.
*YouthBuild submits to random Drug Testing
