YIHS Boarding Application

For Diploma-Seeking & Immersion Boarding Applicants
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Student Information
First Name
Last Name
Current Grade Level
School Presently Attending
Commentsmore details
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Favorite Fruitspick one!
Date of Proposed Entrly
Student Street Address
City
State or Province
Student Cell PhoneIf student doesn't have cell phone please write none
Student Month of Birthpick one!
Student Day of Birthpick one!
Student Year of Birth
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Country of Birth
Country of Citizenship
Language Spoken at Home
Other Languages Spoken
Parent Information Household X
Parent NameFirst and Last
Parent NameFirst and Last
Household X Street Address
Household X City
Household X State or Province
Household X Postal Code
Household X Home Phone NumberIf none, please write "none"
Household X Parent CellIf none, please write "none"
Parent Information Household Y
Household Y Parent NameFirst and Last
Household Y Parent NameFirst and Last
Household Y Street Address
Household Y City
Household Y State or Province
Household Y Postal Code
Household Y Home Phone NumberIf none, please write "none"
Household Y Parent CellIf none, please write "none"
Student Questionnaire
My preferred date of arrival at YIHS is:
My preferred date of departure from YIHS is:
Which academic subjects do you most enjoy?
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Do you like to read?
Please list the publications (books, magazines, blogs, etc.) that you have recently read.
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Do you enjoy writing
What kind of things have you written?
Please describe any paid occupations you have held.
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Please describe any volunteer opportunities you have pursued.
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Do you enjoy Art and Craft?
Please list the arts and crafts you most enjoy
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Do you enjoy singing?
Do you enjoy acting?
What instruments are you able to play?
Are you able to read music?
Please list productions you have been a part of and your role in those productions
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How much time do you spend on the computer every week?pick one!
Please list some of your favorite television shows or movies
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How often do you use your cellphone?
How much time per week do you spend watching television (including movies)pick one!
What do you use the computer for?
How often do you play video games?
What sports do you play regularly?
Please describe your relationship to nature.
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How do you spend your free time?
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Please list your regular responsibilities at home.
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How do you feel about the use of alcohol, nicotine, marijuana, and other drugs?
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Students and Faculty at the Youth Initiative High School aspire to a healthy, engaged academic and social life, and students here agree not to use alcohol or other drugs during the school day or during school activities.
Do you agree to this?
I want to participate in the Youth Initiative High School and I have read and understand the Vision and Purpose Statement. I commit to abide by the school policies, standards, values and guidelines as I enter into and participate in the Youth Initiative High School.
Type name to sign in agreement to the above.
Please upload a picture of yourself
Upload
Please list the names of 3 non-family references.
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In about 300 words write an essay explaining why you want to attend YIHS.*We recommend composing your essay in a word processing program and pasting it into the below answer field.
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Parent Questionnaire (to be completed by the applicant's parent)
Name of Parent completing this formyour full name
My son/daughter has a valid passport.
My child is a U.S. citizen
I am willing and able to provide transportation for my son/daughter from my home to the Viroqua region.
I am willing and able to acquire an F-1 student visa for my son/daughter
I am aware that we are responsible for incidental costs our student may encounter (i.e., social events, clothing, class fees, etc.)
English language fluency of parent(s)
Please describe any serious illnesses or injuries in your child’s life.
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What do you consider to be your child’s academic strengths and weaknesses?
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Please describe your student’s relationship with peers.
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Please describe your student’s relationship with teachers.
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Please describe any psychiatric treatment or psychological counseling undergone by your student.
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Please describe any emotional, behavioral, or learning challenges experienced by your student.
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Please describe your student’s relationship to drugs, including alcohol and nicotine.
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Please share any other information that may help the Youth Initiative and your host family to understand and serve your student.
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Health Information
Information submitted in this section will have no effect on any admission decisions. Please list any medications your child takes on a regular basis.
Please list any medications your child takes on a regular basis.If no medications please type “none”
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Please list and describe all of your child’s allergies.If no allergies please type “none”
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Has your child ever had seizures?
Please check all medications that can be given to your child in the event of a headache or other minor ailment.
Health Insurance Company Name and Address
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Health Insurance Policy No.
My child has received all vaccines dictated by my personal conviction.
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