Student Application Form
Name ______Date of Birth ______
Address ______Grade ______
______Credits Earned______
Student phone number______Student email address______
List all High School’s attended______
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Do you participate in sports ____yes no____ if yes, what sports______
Do you have an IEP on file ____yes no____ if yes, please provide a copy with your application.
(Circle one)
What Vocational Track would you like ____Construction ____ Automotive ____ Culinary
____ T-Shirt Shop ____ CNA____Computer Applications
What campus would you like to attend ____Colorado Springs ____Walsenburg ____Pueblo ____Salida
My Parent/Guardian and I have read and understand the Student Contract ______yes ______no
(Circle one)
Parent/Guardian’s Name ______
Parent/Guardian’s Signature ______
Parent/Guardian Signature is required for The Career Building Academy to review your application
Parent/Guardian’s phone number______
Parent/Guardian’s email address______
Please return your completed The Career Building Academy Student Application Form along with your answers to the questions on the back to The Career Building Academy prior to the close of the school year.
The Career Building Academy will review all applications and conduct testing and interviews no later than 1 week prior to the 1st day of the 2015-2016 school year. You will be contacted by phone and/or mail to set-up the testing/interview time.
Thank you for your interest in The Career Building Academy,
The Career Building Academy Staff
Please answer the following questions on the lines provided.
1. What are your occupational goals? Do you plan to attend college?
2. What specifically interests you about attending The Career Building Academy?
3. What do you hope to gain personally by attending The Career Building Academy?
4. In your opinion, what constitutes “hard work”?
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Student Information
FULL NAME (first/Middle/Last) / Grade / M/F / DOB / SSN / Previous SchoolEthnicity: Hispanic/Latino? Yes or No
At least one race Category must also be select below: (check all that apply)
Race: American Indian/Alaskan Native____ Asian____ Black /African American____ White____ Native Hawaiian/Pacific Islander____
Required State/Us Data: 1) Month/Year students began attending Colorado Public Schools Continuously:
Note: Home Schooled Programs are not considered a Public School for both questions. PK & K do not apply
2) Initial Grade students began schooling in US Public School systems: PK__ K__ 1ST__ If other list Year: ______
Household Information: List parents/step parents students live with currently. “Secondary Household” Section Below is for the parent that is not part of this household. Indicate if either parent is a Step Parent.
Father’s Name: ______Mother’s Name: ______
Physical Address:______
Mailing Address (If Different): ______Bus Route ____Bus Stop______
County Of Residence: El Paso____ Elbert____ Huerfano____ Pueblo____ Other______
Live in District? ______If No List District ______
Home Phone: ______Father’s Cell: ______Mother’s Cell: ______
Email Address: ______or None ______
(Email addresses are used for school and teacher notifications)
Father’s Employment: ______Work Phone: ______Cell: ______
Mother’s Employment: ______Work Phone: ______Cell: ______
Secondary Household: (If student does not live with both parents) Address needed for mailing & email portal notifications.
Name: Main Contact Number: ______Contact In Case Of Emergency? ______
Address: ______Email: ______Parent Portal Access?______Do you want report cards mailed? ______
Contacts for Emergency or Release: (INDICATE IF CONTACT IS FOR EMERGENCY, RELEASE TO, OR BOTH)
NAME / PHONE NUMBER / RELATIONSHIPS / EMERGENCY / RELEASEHospital Preferred: ______Family Doctor: ______Phone: ______
In the case of a medical or dental emergency involving my student, I authorized TCBA to secure medical/dental care and treatment for my student and/or arrange for my student to be transported to an emergency health care facility.
Parent Guardian Signature: ______Date: ______
Student Health Care Plan & Special Conditions Form
Student’s Full Name: ______
*This information will be shared with professional school staff who will work with your student. Please contact the school if you have any additional concerns. The school will contact you if additional clarification is needed.
What is the health condition?
What are special considerations for the school? (Describe: asthma triggers, activity restorations, special diet, instructions, etc. that apply)
List of medications taken at home and at school.
*If your student will take any medication at school, obtain a permission slip that must be signed by a doctor. This includes inhalers for asthma, prescription medications, and over – the counter medications such as Tylenol or cough drops.
Name of medication / Dose / Time taken at home / Time Taken at schoolAre there any special instructions to handle in case of an emergency? ______
______I verify that the information on this form is true and complete of the best of my knowledge. I understand that it is my responsibility to inform the school TCBA staff of any changes in my student’s health. I authorize TCBA to seek emergency care if and when they deem necessary. All efforts will be made to contact the parents and then emergency contacts. All efforts will be made to contact the parents and then emergency contacts. All emergency costs are at the expense of the family.
Parent Signature: ______Date: ______
The following is for the TCBA staff to complete:
TCBA staff health concern:Assessment:
Goals:
Objectives:
Teachers Intervention:
Nursing Intervention:
Evaluation:
TCBA Staff Signature: ______Date: ______
Student Health Information Form
Students NameGrade / Date of Birth / Gender
If the school TCBA staff needs clarification of the information, he/she may call:
Parents NameDaytime Phone
Does your student have any of the following?
Urinary Tract Infection / YES / NOFrequent Bed Wetting / YES / NO
Bladder Control Problems / YES / NO
Bowel Control Problems / YES / NO
Asthma / YES / NO
Lung/Breathing Problems / YES / NO
Allergies: Food, Drug, Other / YES / NO
Heart Trouble / YES / NO
Diabetes / YES / NO
Bee Sting Allergy / YES / NO
Takes Regular Medication / YES / NO
Other: / YES / NO
YES / NO
Vision Problem/Glasses / YES / NO
Hearing Problem / YES / NO
Hearing Aides / YES / NO
Speech Difficulty / YES / NO
Prosthetic Devices / YES / NO
Headaches/ Head Injury / YES / NO
Frequent Colds / YES / NO
Frequent Ear Infections / YES / NO
Ulcer / YES / NO
Bone /Joint Disease / YES / NO
Epilepsy/Seizures / YES / NO
Behavior Diagnosis: ADHD, etc. / YES / NO
Psychiatric Diagnosis: OCD, BPD, etc. / YES / NO
Name Of the Physician
Phone
Address
Insurance Type
Number
State law requires that an Immunization Record be provided to the school district in order for your student to attend school. The school TCBA staff will notify you if the immunizations are not up to date. If you are opposed to immunizations or your student is exempt for medical reasons, the back of the immunization card at the school needs to be signed. Please contact the school TCBA staff with questions.
I verify that the information on this form is true and complete to the best of my knowledge. I understand that it is my responsibility to inform the school TCBA staff of any changes in my student’s health
Parent Signature: ______Date: ______
TCBA Staff Signature: ______Date: ______
HOME LANGUAGE SURVEY
FEDERAL LAW FORM (PARENT CHECKLIST)
Federal and state regulations require schools to determine the language(s) spoken and understood by each student. This information is requested so that the schools may provide appropriate instruction. Thank you for this information.
District: ______School: ______Teacher: ______Grade: ______Student ID #: ______Date Enrolled: ______
To Be Filled Out By School Staff:
To Be Filled Out By Parent / Guardian:
(PLEASE PRINT)Student’s Name
(Last) ______(First) ______(Middle) ______
Date Of Birth: ______Parent/Guardian(s) Name: ______
What Language or Languages did your student use when he/she first began to speak? ______
What Language or Languages do you (parents or Guardians) use when you speak to your student? ______
Do the adults in your home (parents, guardians, grandparents or any other adult) speak to each other in a language other in a language other than English on a regular basis? YES NO
If yes what language(s) are spoken? ______
If a language other than English has been indicated above, please continue:
Does your student understand the conversation? YES NODoes your student participate in the conversation even though he/she might use English? YES NO
What language(s) does your student read? ______
What Language(s) does your student wright? ______
Did your student attend school in another country? YES NO
If yes, in which country? ______
What language(s) were used for instruction? ______
Student’s Country of Birth? ______
Date Student Entering Colorado? ______
Date Student Entering USA? ______
Parent/Guardian Signature: ______Date: ______
Conditional Admissions for The Career Building Academy
Dear ______,
Your request for admission to TCBA has been accepted on a conditional basis. However, should it be subsequently determined that you:
1. Have a physical or mental disability such that you cannot reasonably benefit from the program available;
2. Have a physical or mental disability or disease causing the attendance of you to be inimical to the welfare of your pupils;
3. Have graduated from the 12th grade or any other school or have received a document evidencing completion of the equivalent of secondary curriculum (i.e., a GED)
4. Fail to meet the requirements of age having reached the age of 21;
5. Have been expelled from any school district during the preceding 12 months or have engaged in behavior in another school district during the previous 12 months that is detrimental to the welfare or safety of other pupils or of school personnel;
6. Have failed to comply with the provisions of part 9 of article 4 of title 25, C.R.S.
(“School Entry Immunization”)
7. Have failed to provide a current IEP;
8. Have not made sufficient progress in 30 days;
then your conditional admission shall be revoked and you shall be denied admission to this school.
I have read and agree to the above conditions.
Student Signature: ______Date: ______
Parent/Guardian Signature: ______Date: ______
Administrator Signature: ______Date: ______
Acceptable Use Policy
This policy is designed to guide students in the acceptable use of computer equipment and programs found in any classroom or other school facility. Failure to abide by these guidelines can result in the limitation or revocation of computing privileges, fines for damaged equipment, and/or other disciplinary action.
TCBA reserves the right to limit access to its networks and to remove or limit access to material posted on school computers. The district recognizes that all members of the community are bound by federal and local laws relating to civil rights, harassment, copyright, security, and other statutes relating to electronic media.
1. The school network is for academic use only – i.e., education and research. Games, chat, social websites, inappropriate materials, personal webmail, streaming radio, and other non – academic applications are NOT allowed.
2. Users may NOT encroach on other’s use of computer resources. Such activities would be include, but are not limited to, tying up computer resources with excessive game playing or other applications; modifying computer settings; physically damaging machine, sending harassing messages, either locally or over the internet; using excessive amounts of storage or bandwidth; introducing any computer viruses or damaging programs onto the District’s hardware or software; physically damaging systems; attempting to circumvent computer settings; using another user’s account.
3. Students are NOT allowed to download or install personal programs. Downloads can be allowed by the classroom instructor on a needs basis. Students can be given permission to download needed materials, but cannot do this at their own discretion.
4. Peer - to – peer programs are strictly forbidden for all users in the district.
5. If a student’s online activity (regardless of content) is disrupting his or her class work, then this alone may result in the loss of online privileges.
While TCBA strives to maintain adequate protection for students and staff through Internet content filtering (as required by law), it is ultimately the student’s responsibility to visit sites that are appropriate in the academic setting. The visitation/downloading of material that is inappropriate (e.i. pornographic, violent, obscene, or otherwise academically unacceptable) is treated with the same response as if this literature were physically brought onto school grounds.
Students who abuse online privileges will be taken offline for a minimum of two weeks. Additional consequences may be given by the school administration if they deem it necessary based on the infraction.
Student Print: ______Student Signature: ______
Date: ______
Parent/Guardian Print: ______Parent/Guardian Signature: ______
Date: ______
Student In Unpaid Work Based Learning Experience and Worker’s Compensation
To Whom It May Concern:
By entering into contract with The Career Building Academy, ______will forfeit any claims against The Career Building Academy for any student injuries that may occur in the classroom lab or on the job site. ______understands by accepting all of the Colorado State pupil funds for each student enrolled in The Career Building Academy program, this contract will hold harmless The Career Building Academy in any and all claims to include instructors, board of directors, staff, personnel and trade partners. ______accepts all liability, legal claims, attorney fees and any costs not outlined in the Terms and Conditions of The Career Building Academy contract. This release must be signed by the head administrator of the ______prior to any student enrolling with The Career Building Academy program.
A signed copy of this document will be attached to each student’s contract. Additionally, the student and the student’s parent or guardian must sign where indicated that they have read and understand this agreement between The Career Building Academy and ______.