YIHS Boarding Application For Diploma-Seeking & Immersion Boarding Applicants "" 1 Student Information First Name Last Name Current Grade LevelSelect An Option8th9th10th11th School Presently Attending Commentsmore details0 / Favorite Fruitspick one!AppleOrangeWatermelon Date of Proposed Entrly Student Street Address City State or Province Student Email Student Cell PhoneIf student doesn't have cell phone please write none Student Month of Birthpick one!JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Student Day of Birthpick one!Select An Option12345678910111213141516171819202122232425262728293031 Student Year of Birth0 / 4 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 Parent Email 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 Parent Email 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?0 / Do you like to read?Select An OptionYesNo Please list the publications (books, magazines, blogs, etc.) that you have recently read.0 / Do you enjoy writingSelect An OptionYesNo What kind of things have you written?PoetryShort StoryNovelNon-Fiction EssayResearch Paper Please describe any paid occupations you have held.0 / Please describe any volunteer opportunities you have pursued.0 / Do you enjoy Art and Craft?Select An OptionYesNo Please list the arts and crafts you most enjoy0 / Do you enjoy singing?Select An OptionYesNo Do you enjoy acting?Select An OptionYesNo What instruments are you able to play?GuitarPianoBrassReedDrumsViolinCelloStandup or Electric BassOther Are you able to read music?Select An OptionYesNo Please list productions you have been a part of and your role in those productions0 / How much time do you spend on the computer every week?pick one!Select An Option< 2 hr2-4 hrs5-15 hrs> 15 hrs Please list some of your favorite television shows or movies0 / How often do you use your cellphone?Select An OptionI don't have a cell phoneA few times a weekA few times a daySeveral times a day How much time per week do you spend watching television (including movies)pick one!Select An Option< 2 hr2-4 hrs5-15 hrs> 15 hrs What do you use the computer for?ResearchWorkEntertainmentCommunicationCreative Endeavor How often do you play video games?Select An OptionNeverOccasionallyRegularlyEvery Day What sports do you play regularly?Football (American or Australian)BasketballBaseballVolleyballSoccerTrack & FieldNoneOther Please describe your relationship to nature.0 / How do you spend your free time?0 / Please list your regular responsibilities at home.0 / How do you feel about the use of alcohol, nicotine, marijuana, and other drugs?0 / 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?Select An OptionYesNo 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 yourselfUpload Please list the names of 3 non-family references.0 / Please list the email addresses of the above non-family referencesa valid email Please list the email addresses of the above non-family referencesa valid email Please list the email addresses of the above non-family referencesa valid email 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.0 / 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.Select An OptionYesNo My child is a U.S. citizenSelect An OptionYesNo I am willing and able to provide transportation for my son/daughter from my home to the Viroqua region.Select An OptionYesNo I am willing and able to acquire an F-1 student visa for my son/daughterSelect An OptionYesNoMy child is a U.S. citizen I am aware that we are responsible for incidental costs our student may encounter (i.e., social events, clothing, class fees, etc.)Select An OptionYesNo English language fluency of parent(s)Select An OptionI am able to communicate in English with my child’s host family.I need assistance communicating in English with my child’s host family Please describe any serious illnesses or injuries in your child’s life.0 / What do you consider to be your child’s academic strengths and weaknesses?0 / Please describe your student’s relationship with peers.0 / Please describe your student’s relationship with teachers.0 / Please describe any psychiatric treatment or psychological counseling undergone by your student.0 / Please describe any emotional, behavioral, or learning challenges experienced by your student.0 / Please describe your student’s relationship to drugs, including alcohol and nicotine.0 / Please share any other information that may help the Youth Initiative and your host family to understand and serve your student.0 / 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”0 / Please list and describe all of your child’s allergies.If no allergies please type “none”0 / Has your child ever had seizures?Select An OptionYesNo Please check all medications that can be given to your child in the event of a headache or other minor ailment.IbuprofenAcetameniphenHomeopathic Remedy Health Insurance Company Name and Address0 / Health Insurance Policy No. My child has received all vaccines dictated by my personal conviction.Select An OptionYesNo Submit Form Add some text or HTML here Add some text or HTML here Add some text or HTML here Add some text or HTML here Languagepick one!Select An OptionEnglishFrenchSpanish Languagepick one!Select An OptionEnglishFrenchSpanish Languagepick one!Select An OptionEnglishFrenchSpanish Previous Next
