Student enrollment form new

ACYR STUDENT ENROLLMENT FORM

1ACYR APPLICATION

2AGENCY USE ONLY

3ACYR EXPECTATIONS

4MEDIA RELEASE

5MEDICAL RELEASE

6ACYR USE ONLY

ACYR APPLICATION

Name *

First

Last

Age *

Last 5 digits of Social (for SNAP) *

D.O.B. *

Phone *

Address *

City *

Zip code *

Alternate contact name *

Phone number *

Basic Information

Is your living situation permanent? *

What is your employment status? *

Employed full time
Employed part time
Unemployed

Are you or anyone in your house receiving: (check all that apply) *

TANF
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Pell Grant
Unemployment
Refugee Cash Assistance
N/A

Are you or anyone in your household receiving SNAP/Foodstamps? *

If not, would you like to apply for SNAP/Foodstamps? *

Gender *

Male
Female
Transgendered
I choose to not self-identify

Race: *

Caucasian/White
African American
Asian
Hawaiian/Pacific Islander
Native American
Not self-identified
Other: Enter here

Hispanic, Latino or Spanish Origin? *

Education

Are you currently attending school?

If yes, what are you attending? (please select the education type from below) *

Attending middle school
Attending high school
Attending alternative/Charter school
Attending college/Technical school
Attending a dropout recovery program
N/A

Have you ever had a 504 plan or IEP *

Current Status

Citizenship status *

US citizen
Lawful alien/refugee
Permanent resident
Employment authorization
Other

Have you been out of school and unemployed in the past 90 days (3 months)? *

Have you been out of school and unemployed in the past 180 days (6 months)? *

Additional Information (Mark all that apply) *

Disability
Experiencing homelessness
Basic skills deficient
Parenting
Foster child (current or previous
Low income
Single parent
Overaged & under-credited
Speaks limited English
I would like someone to contact me regarding these barriers or others not listed

Have you had any involvement with the Justice System? *

Have you been on probation, parole or diversion? *

I certify that the information on this application is accurate to the best of my knowledge. I understand that my willful misstatement of the facts will cause my forfeiture of rights in any ACYR Programs and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for ACYR. I further understand and agree that my social security number and other information on this application will be provided to other government agencies if required by law.

PARTICIPANT: BY TYPING YOUR NAME BELOW YOU ATTEST THAT YOU ARE THE PERSON COMPLETING THIS APPLICATION

Name *

Date *

PARENT/GUARDIAN IF UNDER THE AGE OF 18
By typing your name below you attest that you are the person assisting the participant in completing this application

Name *

Enter Date *

AGENCY USE ONLY

If ABE applicant was denied ABE services, what was the reason: *

Denied due to being ineligible for the ABE program
Denied due to immigration status

ACYR program(s) referred to: *

Adult Education
City View High school
City View NOW

SNAP Voluntary Participation Agreement

WELCOME TO THE SUPPLEMENTAL NUTRITION ASSISTANCE EMPLOYMENT AND TRAINING (SNA E&T) PROGRAM!
By volunteering to participate in this program, you will have the opportunity to receive services that will help you get a job or get a better job if you’re already employed. In cooperation with other state and local agencies and community-based organizations, the SNA E&T Program is offering you the opportunity to receive services which could include case management, assistance with job searching and:
• Job readiness
• Work experience
• Community service
• Education and/or training
• Registered apprenticeship
• Job retention services
You have a strong chance of getting a job by volunteering for this program. These services will be provided at no cost to you. SNA E&T Program services are funded by the Supplemental Nutrition Assistance Program (SNAP) and participating community-based organizations. Should you choose to take this opportunity, you may also be aided with transportation, clothing assistance and other costs related to participating. This is a voluntary program. You are not required to participate to continue receiving SNAP benefits (Food Stamps). If you would like to be a part of this program, please sign the statement below:
• I understand that this is a voluntary program and does not affect my SNAP benefits.
• I understand that while this is a voluntary program, I agree to fully participate to increase my chances of finding employment or getting a better job.

Signature *

Want to apply for SNAP

SNAP Voluntary Participation Agreement Date *

Print *

Full Name *

Last 5 Numbers of Social Security Number *

ACYR EXPECTATIONS

The purpose of ACYR is to offer comprehensive programming in a coordinated effort with different programs to encourage goal attainment, recognize and reinforce accomplishments and motivate participants to be successful in their endeavors. Staff will strive to provide a caring and supportive environment to help you meet your goals with our agency and will be able to do so with your help. Below are the expectations we have of you during your participation with us to help provide a positive learning environment for you and your peers.

While participating in any of the above activities, I agree to.

Attend training sessions as scheduled
Actively participate in training activities.
Comply with ACYR policies.
Respect the space, individual rights and differences of other participants and ACYR staff.

While in training related activities, I will dress in such a manner that is clean, modest, and not disruptive to the training program. Conditions that will require immediate attention are:

Clothing with drug, alcohol, tobacco, sexual or abusive messages or logos.
Wearing immodest or indecent attire (i.e. see through blouses/shirts, bare midriff, etc.)
Wearing a muscle shirt as a shirt.
Wearing hairnets or other hair covering, including bandannas, hats, and do’ rags.
Bare feet, slippers and other unsafe footwear.
Shorts or miniskirts that do not reach below mid-thigh. g. Clothing implying gang affiliation or activity such as colors, logos, writing, etc.
Sagging pants
I understand if I am dressed inappropriately, I will be given an opportunity to change into appropriate clothing and remain in class or I will be sent home for the day or until dress is appropriate.
GANG RELATED BEHAVIOR will NOT be tolerated. ACYR is neutral territory and is committed to providing a safe training environment. This includes: tagging, gang signs, wearing “gang” colors or affiliation, flags, drawing, etc.
I understand that ACYR is a drug/alcohol-free campus. I will not possess, use, or show up under the influence of drugs and/or alcohol.
I understand that Under the Americans with Disabilities Act, it is the policy of ACYR to make reasonable accommodations for persons with disabilities to allow them to take part or have access to its programs, services, or activities. Individuals with disabilities, who need accommodation, including aids for effective communication such as sign language interpreters or enlarged print materials, are invited to make their needs and preferences known to: Human Resources (602) 252-6721

ATTENDANCE

Students are expected to follow the attendance schedule determined at orientation. If the student must miss class, a phone call, text, or email is expected before class time. If the student has more than four absences in any month, the situations that led to the absences will be discussed, and solutions to any barriers to success will be discussed. The student’s schedule may be adjusted, based on class availability.

TARDY POLICY

Students are expected to be in the classroom at the beginning of class. If the student is not in class on time, he or she may not be admitted. If the student makes prior arrangements as to lateness, staff may admit students into class at any time. Three tardies in any month will constitute an absence.

BEHAVIOR

Students are expected to participate in all scheduled educational activities. In-attention or disruptive behavior is not tolerated. If such behavior occurs, staff may give the student an opportunity to display positive behavior. At any time, staff may ask a student to leave for inappropriate behavior. Trash should be placed it trashcans and not the floor or outside. Cell phones must put on silent mode during class.

PARTICIPATION

During services, I may participate in various training activities, such as: Objective Assessment, Education, Employment Skills Training, Internships, Occupational Skills Training, Leadership Development, and Job Search.

**See Participant Handbooks per program for more specific expectations.

By signing this form, I acknowledge that ACYR expectations have been explained to me. I agree to follow the above expectations and understand that if I do not, I may be asked to leave for the day, or be asked not to return.

Print Name *

Signature *

MEDIA RELEASE

I give permission for my child *

I give consent to all photographs, audio recordings, video recordings, and/or work products taken of me/my minor child by ACYR staff or designee. I understand that any such photographs, audio recordings, and/or work product become the property of ACYR and may be used by ACYR for educational, instructional, or promotional purposes determined by the organization in broadcast and electronic media formats now existing or in the future created.

Consent is for Me *

I am 18 years of age or older
my Minor Child

Signature of Student or parent or guardian if under 18 *

Print Name (Student or parent or guardian if under 18) *

Please check one of the options below: *

Yes, I give my consent.
No, I do not give my consent.

Name: *

Name of child: *

I certify that I have full power to give this consent and understand the meaning and effect of this authorization.

MEDICAL RELEASE

Student Name *

Age *

Hospital Preference *

Physicians Name *

Please list any known medical conditions

Please list any known allergies

IN CASE OF EMERGENCY, PLEASE CONTACT *

Parent/Guardian *

Relative/Spouse *

Neighbor/Friend *

Home Phone *

Work/Cell Phone *

PLEASE COMPLETE IF YOUTH IS UNDER 18

Parent/Guardian *

Relationship to Youth *

I hereby consent to, and authorize medical care, diagnoses and treatment for *

when suffering from life threatening condition requiring immediate emergency medical care in the event that I am not immediately available to provide consent and authorize medical care. I also consent to my son/daughter being placed in the ACYR at the discretion of staff personnel.

Youth/Parent/Guardian Signature *

Emergency medical Date *

Student Authorization to Release Information

I *

SS# *

hereby authorize the release of information to ACYR in order to verify participation in education and training; current and past employment, start and termination dates, wages paid, job titles, hours worked, benefits received and source(s) of referral.

Signature of Individual Authorizing Release *

Individual Date *

Print Name of Parent/Guardian *

Signature of Parent/Guardian *

Authorizing Release Date *

I understand that:
The use of ACYR’s computer equipment is a privilege, NOT a right. Students are to use only their assigned computer and login credentials when accessing computers or any electronic media. Abuse of the rules may result in the restriction or cancellation of computer and Internet use privileges. ACYR reserves the right to monitor users’ online activities and to access, review, copy, store, and delete any electronic communication or files accessed on ACYR’s computer and disclose them to others, including police, as it deems necessary. Users should have no expectation of privacy regarding their use of computer or internet access on ACYR property, network, and/or internet access or files, including email. ACYR employs a computer monitoring system that monitors student computer activity real time, records all keystrokes, and allows teachers and staff to copy, control, or shutdown the student’s workstation at any time. In addition, the following rules apply to all ACYR computers at all times:
1. No personal storage devices, cell phones, or music players may be connected to any ACYR computer at any time. Not even for charging, as such devises may contain harmful viruses that can be transferred to the network simply by plugging them in.
2. Do not change the background or screen saver settings unless instructed to do so by the instructor for the purposes of learning how to manage computer settings.
3. Use of proxy servers is strictly prohibited. At no time should you ever attempt to subvert the firewall settings in place at ACYR.
4. No streaming or downloading music. This means you cannot listen to music online, watch music videos on YouTube, or in any other way access music on the internet from your computer. All music put onto ACYR computer must have prior approval from an instructor, must be legally obtained, and is to be used only for meeting the requirements of an assignment.
5. No downloading images for personal use. ONLY images needed for coursework and that do not violate copyright laws may be put on computers.
6. Only class related videos may be viewed and only when instructed to do so as part of an assignment. No other videos, music or otherwise may be viewed at any time while using ACYR computers or networks.
7. No accessing Facebook, Flickr, Twitter, Tumblr, or any other type of social media unless specifically directed to do so by an instructor for educational purposes only.
8. No using the internet to search for information related to drugs, gangs, violence, sex, fighting(human or animal), or weapons at any time.
9. Do not change the password assigned to any user account at any time. This includes your personal access sign in.
10. All computers must be logged off and shut down at the end of use. All laptops must be shut down before being returned.
11. All computer usage at ACYR is monitored, and all computers are enabled with software to track keystrokes, websites and programs accessed, and the ability to screenshot what is being accessed at any time. Access to personal e-mails is allowed, however, ACYR staff and view anything that is accessed. Inappropriate e-mails and pictures accessed may be subject to disciplinary actions.
12. No use of any instant messaging or chat service is allowed on ACYR computers, unless specifically approved by CTE instructor for educational use only.
13. Access to computers and the internet is a privilege and not a right. This privilege may be suspended or terminated at any time for violation of any computer and internet policy rules. Performance will be negatively impacted by loss of computer privileges.
I understand and agree to abide by the above rules. I understand that violation of these rules may result in disciplinary action.

Name (please print) *

Student Signature *

ACYR USE ONLY

Name *

Application Date *

ACYR STUDENT ENROLLMENT FORM

SNAP Voluntary Participation Agreement

Address

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Email