2 - University YES Academy

 UNIVERSITYYESACADEMY
April2016
DearUniversityYESAcademyFamilies:
One of the many things that makes UYA special is that we serve students from Kindergarten
through12thgrade.Thisenablesustobuildauniquecommunitywithfamiliesandstudents.We
arealreadyplanningfornextyearandwanttoconfirmthatyouandyourscholar(s)willbepartof
ourcollegeboundlearningcommunity!
PleasecompleteandreturnthisformbyFriday,April29thindicatingyourintentto
re‐enroll your scholar(s). Once we have received this form, your scholar(s) is
guaranteedaplaceforthe2016‐2017schoolyear.
If you have any questions regarding re‐enrolling your UYA scholar or enrolling a new student,
pleasecallthefrontdeskat(313)270‐2556.
ThankyouforbeingapartoftheUniversityYESAcademyFamily!
-------------------------------------------------------------------------------------------------------------------------------------
Scholar’sName(s) CurrentGrade
________________________________________________________
________________________________
________________________________________________________
________________________________
________________________________________________________
________________________________
YES,Myscholar(s)willbereturningtoUniversityYESAcademyin2016‐2017.
Pleasecompletethefollowingre‐enrollmentdocumentation.
No,Myscholar(s)willnotbereturningtoUniversityYESAcademyin2016‐2017.
Reason:____________________________________________________________________________________________
Parent/GuardianName:_________________________________________________________
Parent/GuardianSignature:_____________________________________________________Date:____________________
14669CurtisStreetDetroit,MI48235(O)313.270.2556(F)313.646.6887
UNIVERSITY YES ACADEMY
2016-2017 Re-Enrollment
Please complete all portions of the re-enrollment packet. All enrollment requirements must be completed by
the Friday, April 29, 2016. All requirements and documents must be completed in order to finalize enrollment
at University YES Academy.
Please complete and return the following forms:
 Enrollment Application
 Field Trip and Media Release
 Health & Medication Form
 Federal Lunch Application
 Concussion Information Form
 Bussing Request Form
(if requesting bussing)
Staff Initials
Staff Initials
Staff Initials
Staff Initials
Staff Initials
Staff Initials
________________
________________
________________
________________
________________
________________
Date Rec’d ________________
Date Rec’d ________________
Date Rec’d ________________
Date Rec’d ________________
Date Rec’d ________________
Date Rec’d ________________
Please provide a copy of the following documents:
 Parent/Guardian's ID
Staff Initials ________________ Date Rec’d ________________
(Driver's License or State ID)
For UYA Office Use Only:
Student’s Name
Completion Date
File Checked by
Audit by
Student Records Received
14669 Curtis St., Detroit, MI 48235 | universityyesacademy.org | (313) 270-2556 P | (313) 646-6887 F
UNIVERSITY YES ACADEMY
2016-2017 Re-Enrollment
Thank you for your interest in InspirED Education's University YES Academy. Please complete all portions of the Enrollment Application to be considered.
You may also submit your application online at http://universityyesacademy.org/enroll. Please conplete and submit your application by Friday, April 22,
Application Information
Date
/
Applying
for School
/
(Please check one.)
 Elementary (K-5th)
 Middle (6th-8th)
 High (9th-12th)
Applying
for Grade
(Please check one.)
ES - K 1st 2nd 3rd 4th 5th
MS - 6th 7th 8th
HS - 9th 10th 11th 12th
Student Information
Last
Name
Date of
Birth
First
Name
/
/
Ethnicity
Middle
Name
Am. Indian/ Native
Black/AA Asian
Hispanic
Race
Non-Hispanic
White
Hawaiian/Pacific Islander
Gender

(Please check one.)
Male
Female
Contact Information
Home Address
Apt #
City
State
Zip
Does your scholar have an IEP, 504 plan, and/or
require special services?? (Please check one.)
Home Phone
Yes
No
If you checked yes, please describe any
special services your child receives
Parent/Guardian Information
Guardian #1
Telephone
(Home)
Last Name
-
First Name
-
Telephone
(Cell)
Relationship to Scholar
-
-
Telephone
(Work)
-
-
Email
Address
Guardian #2
Telephone
(Home)
Last Name
-
First Name
-
Telephone
(Cell)
Relationship to Scholar
-
-
Telephone
(Work)
-
Email
Address
14669 Curtis St., Detroit, MI 48235 | universityyesacademy.org | (313) 270-2556 P | (313) 646-6887 F
-
UNIVERSITY YES ACADEMY
Emergency Instructions and Medical Information
Name of person(s) other than the parents/guardians to whom the child can be released to: (Identification will be required to pick up the child.)
Name 1
Name 2
Name 3
Name 4
In the case of an emergency, we will attempt to contact the parents or guardians first. In the event we cannot do this, please provide two emergency
contacts.
Name
Cell Phone
-
-
Name
Cell Phone
-
-
I give permission to University YES Academy to secure emergency medical treatment for previously
named minor child while in school’s care.
I DO NOT give permission to University YES Academy to secure emergency medical treatment for
previously named minor child while in school’s care.
Additional Information
In the case of separated or divorced parents, are there any legal restrictions on the release of your child to either parent? If yes, please
explain. (We require a copy of formal documentation to keep in your child’s file.)
McKinney-Vento Act Questionnaire:
The answers to the following questions can help determine the services this student may be eligible to receive the McKinney-Vento Act 42 U.S.C. 11435.
1.
2.
3.
4.
Is this student’s home address a temporary living arrangement?
Is this a temporary living arrangement due to loss of housing or economic hardship?
Is this student in temporary or emergency foster care placement?
As a student, are you living with someone other than your parent or legal guardian?
Yes
Yes
Yes
Yes
No
No
No
No
If you answered YES to any of the above questions, please complete the remainder of this section.
5a. Where is this student currently living?
Hotel/Motel
Shelter
Transitional Housing
Group Home With another family in house or apartment
Temporary/emergency foster home
Moving from place to place
In a location not designated for sleeping
5b. With whom does the student currently live?
Both parents
One parent
One parent and another adult
Relative, friends or other adults.
Additional Information:
InspirED Education is dedicated to serving all students, including those who are non-English speaking or require special services. These questions have
no impact on admissions.
6.
Are you currently a member of the University YES Academy Family?
Yes
No
7.
What language is spoken in the child’s home most of the time?
English
Spanish
8.
Does your child have an IEP (Individual Education Program) or is receiving Special Education services?
9.
How did you hear about InspirED Education| University YES Academy?
Online search
Flyer
Mailing
Daycare
Billboard
Bus Ad
Other
Yes
No
Other
Consent & Signature:
By submitting this application, I indicate my desire to enroll my student. By signing this application, I am acknowledging that if accepted to UYA, I will
comply with all rules and policies. I understand that admission is not guaranteed.
Date:
Parent/Guardian Signature:
Applications may be submitted in person, by mail, fax, or online.
Mail: InspirED Education c/o Admissions; 14669 Curtis Street, Detroit, Michigan 48235
Fax: 313.646.6887 ● Online: http://uninversityyesacademy.org/enroll
Non-Discrimination Statement: A charter school shall not discriminate against any student on the basis of ethnicity, national origin, gender, disability or any other ground that would be unlawful if done by a school. Admission of students shall not be limited on the
basis of intellectual ability, measures of achievement or aptitude, athletic ability, disability, race, creed, gender, national origin, religion or ancestry. A school may not require any action by a student or family (such as an interview, an essay, attendance at an
information session, etc.) in order for an applicant to either receive or submit an application for admission to that school. However, a charter school is permitted to be established as a single-sex charter school or a charter school designed to provide expanded
learning opportunities for students at-risk of academic failure or students with disabilities and English language learners.
14669 Curtis St., Detroit, MI 48235 | universityyesacademy.org | (313) 270-2556 P | (313) 646-6887 F
UNIVERSITY YES ACADEMY
Field Trip and Media Release
I understand that as part of attendance scholars may occasionally take field trips with the school. It is
understood that the school will take all reasonable precautions to ensure against the possibility of
accidents. However, parent(s)/guardian(s) should understand that University YES Academy or the
teacher in charge is not liable for accidents occurring to children either on school premises or while on
field trips as part of the school’s activities.
Information concerning a specific field trip such as date, time or departure, destination, cost and
means of transportation will be sent to parent/guardian by the teacher prior to the field trip.
I give my permission for my scholar to attend school field trips.
Student’s Name:
Parent or Guardian Signature:
Date:
There may be times during the school year when media or others wish to photograph or videotape your
son/daughter at University YES Academy.
I give my permission to University YES Academy to release items concerning school activities of my son/
daughter to the media. I also give my permission for my child’s name, portrait, picture, or voice to be used
for display or in promotion material for the school or its management company, InspirED Education, and/
or in local media coverage of school events.
Student’s Name:
Parent or Guardian Signature:
Date:
14669 Curtis St., Detroit, MI 48235 | universityyesacademy.org | (313) 270-2556 P | (313) 646-6887 F
UNIVERSITY YES ACADEMY
Health & Medication Form
Is there any medical information you would like to share with University YES which might help us better serve your child?
Are there any restrictions on your child’s physical activities at school? If yes, please explain.
Please list any known allergies:
All medication administered at the school MUST be labeled in a child-proof container with the name of medication, student’s
name, and instructions, such as dosage and time to be administered.
Student’s Name:
Name of Medication:
Diagnosis/Purpose of
Medication:
How is medication to be
administered?
Should the school be aware
of any adverse reactions or
precautions?
The undersigned parent/guardian authorizes University YES Academy through its administrators and/or staff to administer
medication or to supervise the taking of medication by my child.
It is understood that the undersigned parent/guardian shall immediately notify the school personnel in writing in the event the
prescription shall be discontinued or modified. Refills of the prescription shall be the responsibility of the parent/guardian.
Further, the undersigned shall release and indemnify University YES Academy and its employees from any liability or damage,
which may result from the administration of said medication as prescribed by the physician.
Student’s Name:
Parent or Guardian Signature:
Date:
14669 Curtis St., Detroit, MI 48235 | universityyesacademy.org | (313) 270-2556 P | (313) 646-6887 F
PARENT & ATHLETE CONCUSSION
INFORMATION SHEET
WHAT IS A CONCUSSION?
A concussion is a type of traumatic brain injury that changes
the way the brain normally works. A concussion is caused by
a bump, blow, or jolt to the head or body that causes the
head and brain to move quickly back and forth. Even a
“ding,” “getting your bell rung,” or what seems to be a mild
bump or blow to the head can be serious.
WHAT ARE THE SIGNS AND
SYMPTOMS OF CONCUSSION?
Signs and symptoms of concussion can show up right after
the injury or may not appear or be noticed until days or
weeks after the injury.
If an athlete reports one or more symptoms of concussion
after a bump, blow, or jolt to the head or body, s/he should be
kept out of play the day of the injury. The athlete should only
return to play with permission from a health care
professional experienced in evaluating for concussion.
SYMPTOMS REPORTED
BY ATHLETE:
•
•
•
•
•
•
•
•
•
•
Headache or “pressure” in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not “feeling right” or is “feeling down”
DID YOU KNOW?
• Most concussions occur without loss of
consciousness.
• Athletes who have, at any point in their lives,
had a concussion have an increased risk for
another concussion.
• Young children and teens are more likely to
get a concussion and take longer to recover
than adults.
[ INSERT YOUR LOGO ]
SIGNS OBSERVED
BY COACHING STAFF:
•
•
•
•
•
•
•
•
•
•
Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can’t recall events prior to hit or fall
Can’t recall events after hit or fall
“IT’S BETTER TO MISS ONE GAME
THAN THE WHOLE SEASON”
CONCUSSION DANGER SIGNS
WHY SHOULD AN ATHLETE REPORT
THEIR SYMPTOMS?
In rare cases, a dangerous blood clot may form on the
brain in a person with a concussion and crowd the brain
against the skull. An athlete should receive immediate
medical attention if after a bump, blow, or jolt to the
head or body s/he exhibits any of the following danger
signs:
•
•
•
•
•
•
•
•
•
•
•
If an athlete has a concussion, his/her brain needs time to
heal. While an athlete’s brain is still healing, s/he is much
more likely to have another concussion. Repeat concussions
can increase the time it takes to recover. In rare cases,
repeat concussions in young athletes can result in brain
swelling or permanent damage to their brain. They can even
be fatal.
One pupil larger than the other
Is drowsy or cannot be awakened
A headache that gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsions or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness
should be taken seriously)
STUDENT-ATHLETE NAME PRINTED
STUDENT-ATHLETE NAME SIGNED
WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?
1. If you suspect that an athlete has a concussion, remove
the athlete from play and seek medical attention. Do not
try to judge the severity of the injury yourself. Keep the
athlete out of play the day of the injury and until a health
care professional, experienced in evaluating for
concussion, says s/he is symptom-free and it’s OK to
return to play.
DATE
PARENT OR GUARDIAN NAME PRINTED
2. Rest is key to helping an athlete recover from a
concussion. Exercising or activities that involve a lot of
concentration, such as studying, working on the computer,
and playing video games, may cause concussion symptoms
to reappear or get worse. After a concussion, returning to
sports and school is a gradual process that should be
carefully managed and monitored by a health care
professional.
PARENT OR GUARDIAN NAME SIGNED
DATE
3. Remember: Concussions affect people differently. While
most athletes with a concussion recover quickly and fully,
some will have symptoms that last for days, or even
weeks. A more serious concussion can last for months or
longer.
JOIN THE CONVERSATION
TO LEARN MORE GO TO
www.facebook.com/CDCHeadsUp
>> WWW.CDC.GOV/CONCUSSION
Content Source: CDC’s Heads Up Program. Created through a grant to the CDC Foundation from the
National Operating Committee on Standards for Athletic Equipment (NOCSAE).
2015-2016 Application for Free and Reduced Price School Meals
Approval Date:
Approved for: F
Complete one application per household. Please use a PEN (not a pencil).
D
List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)
Definition of Household
Member: “Anyone who is
living with you and shares
income and expenses, even
if not related.”
MI
Child’s First Name
Student? Yes
Child’s Last Name
Homeless,
Foster Migrant,
Child Runaway
School Name:
No
Check all that apply
STEP 1
R
Children in Foster care and
children who meet the
definition of Homeless,
Migrant or Runaway are
eligible for free meals. Read
How to Apply for Free and
Reduced Price School
Meals for more information.
STEP 2
Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR? Circle one: Yes / No
If you answered NO → Go to Step 3 and complete.
STEP 3
If you answered YES → Write a case number here then go to STEP 4 (Do not complete STEP 3)
Case
Number:
Write only one case number in this space.
Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)
How often?
Please read How to
Apply for Free and
Reduced Price School
Meals for more
information. The
Sources of Income for
Children section will
help you with the Child
Income question. The
Sources of Income for
Adults section will help
you with the All Adult
Household Members
section.
A. Child Income
Sometimes children in the household earn income. Please include the TOTAL income earned by all Household Members
listed in STEP 1 here.
Weekly
Bi-Weekly 2x Month
Monthly
$
B. All Adult Household Members (including yourself)
List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in
whole dollars only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
How often?
Earnings from Work
Name of Adult Household Members (First and Last)
Total Household Members
(Children and Adults)
STEP 4
Child income
Weekly
Bi-Weekly 2x Month
Public Assistance/
Child Support/Alimony
Monthly
How often?
Weekly
Bi-Weekly 2x Month
Pensions/Retirement/
All Other Income
Monthly
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Last Four Digits of Social Security Number (SSN) of
Primary Wage Earner or Other Adult Household Member
X
X X
X X
How often?
Weekly
Bi-Weekly 2x Month
Monthly
Check if no SSN
Contact information and adult signature
“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give
false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”
Street Address (if available)
Printed name of adult completing the form
Apt #
City
Signature of adult completing the form
State
Zip
Daytime Phone and Email (optional)
Today’s date
OPTIONAL
Children's Racial and Ethnic Identities
We are required to ask for information about your children’s race and ethnicity. This information is
important and helps to make sure we are fully serving our community.
Responding to this section is optional and does not affect your children’s eligibility for free or reduced
price meals.
Race (check one or more):
Ethnicity
(check one):
American Indian or Alaskan Native
Hispanic or Latino
Not Hispanic or
Latino
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Verification
The Richard B. Russell National School Lunch Act requires the information on this
application. You do not have to give the information, but if you do not, we cannot approve
your child for free or reduced price meals. You must include the last four digits of the social
security number of the adult household member who signs the application. The last four
digits of the social security number is not required when you apply on behalf of a foster child
or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for
Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR)
case number or other FDPIR identifier for your child or when you indicate that the adult
household member signing the application does not have a social security number. We will use
your information to determine if your child is eligible for free or reduced price meals, and for
administration and enforcement of the lunch and breakfast programs. We MAY share your
eligibility information with education, health, and nutrition programs to help them evaluate,
fund, or determine benefits for their programs, auditors for program reviews, and law
enforcement officials to help them look into violations of program rules.
For School Use Only
Date Selected for Verification:
Date Follow-up/Second Notice:
Confirming Officials Signature:
Follow-up Official’s Signature:
Response Due from Household:
Verification Official’s Signature:
FAP/FIP/FDPIR/Foster Eligibility
Not confirmed
Income
Department of Human
Services
Notice of Eligibility
Verification Results
Reason for Eligibility Change
Wage Stubs
Free to
Reduced
Income
Weekly
Written
Documents
Free to Paid
Household Size
Every 2 weeks
Collateral Contact
Reduced to
Free
Refused to
Cooperate
Twice a month
Agency Records
Reduced to
Paid
Other ________
Monthly
Other ________
No Change
$_________________
Confirmed:
Date of Adverse Notice Sent:
Annual
The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity,
religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program,
or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_fling_cust.html,
or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by
mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
[email protected]. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).
USDA is an equal opportunity provider and employer.
Determining Official's Signature: _____________________________________
Date: ________________ Date Dropped/Withdrawn: _________________ UNIVERSITY YES ACADEMY
2016-2017 Student Ridership Request Form
Rider Address: ________________________________________________________________________
Student Name: ________________________________________________________________________
Student Name: ________________________________________________________________________
Student Name: ________________________________________________________________________
School Bus Route Requested:  BLUE
School Bus Stop # on route:
A
 RED
B
C
D
Grade: __________________
Grade: __________________
Grade: __________________
 YELLOW
 GREEN
E
G
F
H
I
J
Parent(s)/Guardian(s) Name: ________________________________________________________________________________________
Best Contact Numbers (s): ____________________________________________________________________________________________
Date of Application: ________________________________________________
ROUTE 1- BLUE
A.
Southfield Svc. Dr. & W. Warren Ave.
B.
Minock St. & W. Warren Ave.
C.
20405 Schoolcraft (CITY MISSION)
D.
Grand River Ave. & Southfield Svc. Dr. (FOODLAND)
E.
Telegraph Rd. & W. 7 Mile Rd.
F.
Lahser Rd. & W. 7 Mile Rd. (BURGER KING)
G.
W. 7 Mile Rd. & Evergreen Rd. (WALGREENS)
ROUTE 2- RED
A.
20500 W. M-10 Service Dr. (CRANBROOK MOTEL)
B.
Florence St. & Schaefer Hwy (SE BUS STOP)
C.
Linwood St. & W. Grand Blvd. (VALERO STATION)
D.
Linwood St. & W. Davison (McDONALDS)
E.
Woodward Ave. & Manchester St. (CVS)
F.
W. McNichols Rd. & Livernois Ave. (McDONALDS)
G.
18600 Livernois Ave. (LIVERNOIS SQUARE)
H.
W. 7 Mile Rd. & Meyers Rd. (HOME DEPOT)
I.
W. 7 Mile Rd. & Schaefer Hwy. (GREAT. EMMAN.)
J.
W. 7 Mile Rd. & Hubbell St.
ROUTE 3- YELLOW
A.
E. 7 Mile Rd. & Moenart St.
B.
Gratiot Ave. & E. Outer Dr. (RITE AID)
C.
W. Chicago St. & Schaefer Hwy. (SUBWAY)
D.
Hubbell St. & Grand River Ave. (CAR. COM. CTR.)
E.
Grand River & Greenfield Rd. (WALGREENS)
F.
Puritan St. & Greenfield Rd. (GREENFIELD MKT)
ROUTE 4- GREEN
A.
Providence Dr. & Oxley Rd.
B.
9065 Burt Rd.
C.
Van Buren & Woodmont Ave. (GARDENVIEW ESTS.)
D.
Plymouth Rd. & Southfield Svc. Dr. (OIL EXCHANGE)
E.
W. 7 Mile Rd. & Evergreen Rd. (WALGREENS)
F.
W. McNichols Rd. & Greenfield Rd. (MCDONALDS)
G.
W. 7 Mile Rd. & Southfield Svc. Dr. (MOBIL GAS)
H.
W. 7 Mile Rd. & Greenfield Rd. (CVS)
Pick Up (M-F)
6:33am
6:36am
6:47am
6:54am
7:03am
7:06am
7:08am
Pick Up (M-F)
6:05am
6:17am
6:34am
6:43am
6:51am
6:55am
7:00am
7:04am
7:14am
7:15am
Pick Up (M-F)
6:40am
6:53am
7:27am
7:33am
7:35am
7:40am
Pick Up (M-F)
6:03am
6:38am
6:47am
6:53am
7:05am
7:10am
7:15am
7:31am
Drop Off (M-F)
TBD
3:46pm
3:35pm
3:30pm
3:22pm
3:20pm
3:17pm
Drop Off (M-F)
TBD
3:36pm
4:24pm
4:12pm
4:08pm
3:58pm
3:48pm
3:30pm
3:25pm
N/A
Drop Off (M-F)
4:04pm
4:16pm
3:27pm
3:21pm
3:18pm
3:13pm
Drop Off (M-F)
3:10pm
4:48pm
4:41pm
4:33pm
4:03pm
3:52pm
3:56pm
3:49pm
*Please note: These are 2015-2016 times are estimates that are subject to change for 2016-2017. If changes are made to the
routes that affect times, notifications will be sent by the Main Office.