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 Tibetan N24 Shoalwater Bay Indian Tribe of Shoalwater Bay P13 Pohpeian A26 Vietnamese Indian Reservation P14 Samoan A27 Asian Write-in: N25 Skokomish Indian Tribe P15 Solomon Islander N26 Snohomish Tribe P16 Tahitian American Indian**/ N27 Snoqualmie Indian Tribe P17 Tokelauan Alaskan Native N29 Spokane Tribe of the Spokane Reservation P18 Tongan N00 American Indian**/ N30 Squaxin Island Tribe of Squaxin Is. Reservation P19 Tuvaluan Alaskan Native N31 Steilacoom Tribe P20 Yapese N36 Alaska Native Write-in: N32 Stillaguamish Tribe of Indians of Washington P21 Pacific Islander Write-in: N33 Suquamish Indian Tribe of the Port Madison Resv. N37 American Indian** Write-in: N34 Swinomish Indian Tribal Community Asian N35 Tulalip Tribes of Washington A00 Asian Washington State Tribes A01 Asian Indian N01 Chinook Tribe Caucasian A02 Bangladeshi N05 Cowlitz Indian Tribe W00 White* A03 Bhutanese N06 Duwamish Tribe Eastern European A04 Burmese/Myanmar N07 Hoh Indian Tribe W01 Bosnian A05 Cambodian/Khmer N08 Jamestown S’Kallam Tribe W02 Herzegovinian A06 Cham N10 Kikiallus Indian Nation W03 Polish A07 Chinese N15 Muckleshoot Indian Tribe W04 Romanian A08 Filipino N16 Nisqually Indian Tribe W05 Russian A09 Hmong N21 Quinault Indian Nation W06 Ukrainian A10 Indonesian N22 Samish Indian Nation W07 Eastern European Write-in: A11 Japanese N28 Snoqualmoo Tribe *Includes, but not limited to, western Europe (Spain, Italy, etc.). **Includes North, Central, and South Americas (e.g., Aztec, Mayan, Inca). Source: OSPI CEDARS Manual Appendices Y and Z. Rev. 5-1-18 Washington Youth Academy State Enrollment Form 7 (continued) ETHNICITY AND RACE CODES RACE CODES (Continued) Middle East/North African Latin American West African W08 Algerian B54 Argentine B84 Beninese W09 Amazigh or Berber B55 Belizean B85 Bissau-Guinean W10 Arab or Arabic B56 Bolivian B86 Burkinabe (Burkina Faso) W11 Assyrian B57 Brazilian B87 Cabo Verdean W12 Bahraini B58 Chilean B88 Ivorian (Cote d’Ivoire) W13 Bedouin B59 Colombian B89 Gambian W14 Chaldean B60 Costa Rican B90 Ghanaian W15 Copt B61 Ecuadorian B91 Liberian W16 Druze B62 El Salvadoran B92 Malian W17 Egyptian B63 Falkland Islander B93 Mauritanian W18 Emirati B64 French Guianese B94 Nigerien (Niger) W19 Iranian B65 Guatemalan B95 Nigerian (Nigeria) W20 Iraqi B66 Guyanese B96 Saint Helenian W21 Israeli B67 Honduran B97 Senegalese W22 Jordanian B68 Mexican B98 Sierra Leonean W23 Kurdish Kuwaiti B69 Nicaraguan B99 Togolese W24 Lebanese B70 Panamanian C01 West African Write-in: W25 Libyan B71 Paraguayan W26 Moroccan B72 Peruvian W27 Omani B73 South Georgia/ W28 Palestinian South Sandwich Islands Central African W29 Qatari B74 Surinamese B21 Angolan W30 Saudi Arabian B75 Uruguayan B22 Cameroonian W31 Syrian B76 Venezuelan B23 Central African W32 Tunisian B77 Latin American Write-in: (Central African Republic) W33 Yemeni B24 Chadian W34 Middle Eastern Write-in: East African B25 Congolese (Republic of the Congo) W35 North African Write-in: B32 Burundian B26 Congolese (Democratic Republic B33 Comoran of the Congo) Black/African-American B34 Djiboutian B27 Equatorial Guinean B00 Black/African-American B35 Eritrean B28 Gabonese B01 African American B36 Ethiopian B29 Sao Tomean B02 African Canadian B37 Kenyan B30 Principe B38 Malagasy (Madagascar) B31 Central African Write-in: Caribbean B39 Malawian B03 Anguillan B40 Mauritian (Mauritius) B04 Antiguan B41 Mahoran (Mayotte) South African B05 Bahamian B42 Mozambican B78 Botswanan B06 Barbadian B43 Reunionese B79 Mosotho (Lesotho) B07 Barthelemois/Barthelemoises B44 Rwandan B80 Namibian (Saint Barthelemy) B45 Seychellois/Seychelloise B81 South African B08 British Virgin Islander B46 Somali B82 Swazi B09 Caymanian (Cayman Island) B47 South Sudanese B83 South African Write-in: B10 Cuba Dominican B48 Sudanese B11 Dominican (Dominican Republic) B49 Ugandan B12 Dutch Antillean (Netherlands Antilles) B50 Tanzanian (United Republic of B13 Grenadian Tanzania) Other Black/African-American B14 Guadeloupian B51 Zambian C02 Black Write-in: B15 Haitian B52 Zimbabwean B16 Jamaican B53 East African Write-in: B17 Martiniquais/Martiniquaise B18 Montserratian B19 Puerto Rican B20 Caribbean Write-in:

Source: OSPI CEDARS Manual Appendices Y and Z. Rev. 5-1-18