Washington Youth Academy
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Washington Youth Academy State Reporting Enrollment Information and Ethnicity/Race Codes Please complete the attached four-page form and return by fax or postal mail. Do not send the form via e-mail. By Fax: 360-473-2650 OR By Postal Mail – send to: WYA Academic Department 1207 Carver Street Bremerton, WA 98312 --------------------------------------------------------------------------------------- Please contact the WYA Academic Department at 360-473-2657/2602 if there are any questions regarding this form. WYA State Reporting Enrollment Information (CONFIDENTIAL) PURPOSE: Washington State law requires that certain information be reported for students that are enrolled in public school. The purpose of this form is to gather information for mandatory State reporting requirements. APPLICANT'S FULL Date of Birth: ______/_____/_____ LEGAL NAME: (Last Name, First Name, Middle Name) Yes No CITIZENSHIP Is the student a United States citizen? BIRTH COUNTRY What is the student’s birth country? Country: ____________________________ (The physical location of birth - not related to citizenship.) IF NOT BORN IN THE UNITED STATES OF AMERICA (USA) 1. Initial USA Public School Enrollment date: __________________ (example: 09/05/2006) 2. For how many months has the student attended school in the United States (grades K–12) before enrolling in the Washington Youth Academy? __________ 3. For how many months has the student received formal education outside the United States in his/her native language (equivalent to grades K – 12) before enrolling in the Washington Youth Academy? _____________ . Formal education does not include refugee camp schools or other unaccredited programs for children. Native Language refers to the family’s dominant language. PRIMARY LANGUAGE Yes No Is English the primary language the student speaks? "Primary language" means the language most often used by a student (not necessarily by parents, guardians, or others) for communication in the student's place of residence. IF English is not the student’s primary language, please complete the questions below. 1. Enter the student’s primary language: _____________________________. 2. Are the student’s English skills sufficiently deficient or absent so as to impair his or her learning? Yes ____ No _____ 3. Does the student need an interpreter? Yes ____ No _____ 4. Has the student received bilingual services previously at another school through the State Transitional Bilingual Instruction Program? Yes ____ No _____ Yes No Is English the primary language spoken in the student’s home? If not, please enter the primary language spoken in the student’s home: ________________ Yes No Does the parent/guardian need an interpreter? Please note that the Washington Youth Academy does not provide English Language Learner (E.L.L.) services or interpreters. SPECIAL SERVICES Yes No Has the student received Special Education (Individualized Education Plan) or Section 504 accommodation services in the past or does he/she currently receive these services? If yes, please list the approximate date (month/year) these special services began in Washington State: I.E.P. services began: ______________ If ended, the date ended: _______________ 504 services began: _______________ If ended, the date ended: _______________ PREVIOUS ATTENDANCE Yes No Has the student attended ANY school in the Bremerton School District in the past? If yes, what is the school name? ____________ Yes No Has the student attended the Washington Youth Academy in the past? If Yes, which session? ______________ MILITARY PARENT OR GUARDIAN Yes No Please enter a code from the choices below: ______ N No parent or guardian is currently serving as a member of the active duty U.S. Armed Forces, Reserves of the U.S. Armed Forces, or Washington National Guard A Has a parent or guardian who is a current member of the active duty U.S. Armed Forces R Has a parent or guardian who is a current member of the reserves of the U.S. Armed Forces G Has a parent or guardian who is a current member of the Washington National Guard M Has more than one parent or guardian who is currently either a member of the active duty U.S. Armed Forces, Reserves of the U.S. Armed Forces, or Washington National Guard Z No response/refused to state X Data not available PREFERRED NAME Yes No Does the applicant wish to use a preferred name (different than legal name) on unofficial academic records? If yes, please provide the preferred name: Preferred Last Name Preferred First Name Preferred Middle Name Suffix Note: The applicant’s preferred name may be used for unofficial school records, such as progress reports and academic award certificates. The student’s legal name will be used on official school records, including the final grade report, State assessments, and any special education documents. The Washington Youth Academy reserves the right to deny or remove any preferred name for misuse, including misrepresentation, or highly offensive or derogatory names. ACCOMPANIED YOUTH Yes No Is the applicant in the physical custody of a parent or legal guardian? If not, explain: ______________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ FOSTER CARE Yes No Is the applicant currently in the State foster care system, as defined below? Foster care definition: 24-hour substitute care for youth placed away from their parents or guardians, and for whom the State agency has placement and care responsibility. This includes, but is not limited to, placements in foster family homes, foster homes of relatives, group homes, emergency shelters, residential facilities, child care institutions, and pre-adoptive homes. HOMELESS Yes No Does the applicant currently meet one of the homeless categories (below) as defined in the McKinney-Vento Act, Section 725(2)? If yes, please check which category: _________. Shelters: Defined as supervised publicly or privately-operated facilities designed to provide temporary living accommodations. Examples include (but are not limited to) youth who are living in homeless shelters, domestic violence shelters, or transitional housing. _________. Doubled-Up: Defined as youth (including runaway and unaccompanied youth) who are “sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason.” The determining factor is whether the accommodation is a “fixed, regular and adequate nighttime residence.” (The term “similar” is generally understood to include, but not be limited to, such circumstances as family turmoil, domestic violence, incarceration, hospitalization, drug/alcohol treatment, etc.) _________. Unsheltered: Examples include (but are not limited to) youth who live in abandoned buildings, campgrounds, vehicles, trailer parks, FEMA shelters, bus/train stations, abandoned in the hospital, living in substandard or inadequate housing, or on the “streets”. _________. Hotels/Motels: Youth residing in hotels/motels due to lack of alternative housing. SIGNATURES: _______________________________________________________________________ _______/________/_________ Parent/Legal Guardian signature (if applicant is under age 18) Date ______________________________________________________________________ _______/________/__________ Applicant signature (if over age 18) Date Directions: Please fax the completed form to the WYA Academic Department at (360) 473-2650, or send postal mail to: Academic Department, Washington Youth Academy, 1207 Carver Street, Bremerton, WA 98312 - Do not send via email - Washington Youth Academy State Enrollment Form ETHNICITY AND RACE CODES APPLICANT’S FULL LEGAL NAME: ________________________________ Date of Birth: _________/_______/ ETHNICITY CODES ______ H00 Hispanic/Latino H10 Dominican H20 Panamanian H01 Not Hispanic/Latino H11 Ecuadorian H21 Paraguayan H02 Argentine H12 Guatemalan H22 Peruvian H03 Bolivian H13 Guyanese H23 Puerto Rican H04 Brazilian H14 Honduran H24 Salvadoran H05 Chicano (Mexican American) H15 Jamaican H25 Spaniard H06 Chilean H16 Mexican H26 Surinamese H07 Colombian H17 Mestizo H27 Uruguayan H08 Costa Rican H18 Native H28 Venezuelan H09 Cuban H19 Nicaraguan H29 Hispanic/Latino Write-in: Applicants must CIRCLE at least one ethnicity code AND at least one race code. CIRCLE as many codes as applicable. RACE CODES (continued on next page) Native Hawaiian/Pacific Islander Asian (continued) Washington State Tribes (continued) P00 Native Hawaiian/ A12 Korean N02 Confederated Tribes/Bands of the Yakama Nation Other Pacific Islander A13 Lao N03 Confederated Tribes of Chehalis Reservation P01 Carolinian A14 Malaysian N04 Confederated Tribes of the Colville Reservation P02 Chamorro A15 Mien N09 Kalispel Indian Community of Kalispel Reservation P03 Chuukese A16 Mongolian N11 Lower Elwha Tribal Community P04 Fijian A17 Nepali N12 Lummi Tribe of the Lummi Reservation P05 i-Kiribati/Gilbertese A18 Okinawan N13 Makah Indian Tribe of the Makah Reservation P06 Kosraean A19 Pakistani N14 Marietta Band of Nooksack Tribe P07 Maori A20 Punjabi N17 Nooksack Indian Tribe of Washington P08 Marshallese A21 Singaporean N18 Port Gamble S’Kallam Tribe P09 Native Hawaiian A22 Sri Lankan N19 Puyallup Tribe of Puyallup Reservation P10 Ni-Vanuatu A23 Taiwanese N20 Quileute Tribe of Quileute Reservation P11 Palauan A24 Thai N23 Sauk-Suiattle Indian Tribe of Washington P12 Papuan A25