""
1
Student Information
First Name
Last Name
School Presently Attending
Commentsmore details
0 /
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 Year of Birth
0 / 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 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?
0 /
Please list the publications (books, magazines, blogs, etc.) that you have recently read.
0 /
What kind of things have you written?
Please describe any paid occupations you have held.
0 /
Please describe any volunteer opportunities you have pursued.
0 /
Please list the arts and crafts you most enjoy
0 /
What instruments are you able to play?
Please list productions you have been a part of and your role in those productions
0 /
Please list some of your favorite television shows or movies
0 /
What do you use the computer for?
What sports do you play regularly?
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.
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.
0 /
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
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 /
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
0 /
Health Insurance Policy No.
Add some text or HTML here
Add some text or HTML here
Add some text or HTML here
Add some text or HTML here
Previous
Next