Call Us at 800-297-2119Employment Policy Sheet

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STUDENT INFORMATION/DEMOGRAPHICS

Student Name: / / Nickname:
Gender: Birthdate:

Current Physical Address:

Current Mailing Address:

SECTION TWO - PARENT/GUARDIAN INFORMATION

Current Physical Address:

Current Mailing Address:

PRIMARY HEADS OF HOUSEHOLD (With whom does the student reside?)

Primary Household DataPrimary Head of Household 1Primary Head of Household 2

SECONDARY HEAD(S) OF HOUSEHOLD

Does the child have a second parent/residence?
Secondary Household DataSecondary Head of Household 1Secondary Head of Household 2

SECTION THREE - SPECIAL NEEDS / ETHNICITY / HEALTH INFO

Is your child's native tongue a language other than English?
Is the primary language used in your child's home or environment a language other than English?

WIDA-A Access assessment for ELL (English Language Learners) students must be taken as mandated by the Michigan Department of Education as part of the state testing and assessments.

*Students that are English Language Learners must agree to participate in this yearly assessment

HEALTH INFORMATION

Medical information is confidential and will be shared with personnel on a need to know basis.

SPECIAL NEEDS INFORMATION

My child is currently following curriculum leading to a:
Has the student been previously suspended?
Has the student been previously expelled?
Are all immunizations current?
ETHNICITY (Part A) and RACE (Part B)
Race and Ethnicity Both Part A and Part B of the question must be answered.
If either part is not answered, the US Department of Education requires the district to supply an answer on your behalf.
Part A: Ethnicity
(choose only one)
Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardsless of race.)

Part A refers to ethnicity, not race. No matter which box you selected above, please continue to answer
Part B (below) by marking one or more boxes to indicate what you consider your students race to be.
Part B: Race
(Choose one or more)
When choosing more than one, enter % for each ethnicity
%
%
%
%
%
%

SECTION FOUR - PREVIOUS SCHOOL INFORMATION

Enter any previous schools attended below

SECTION FIVE - ADDITIONAL EMERGENCY CONTACT INFORMATION (NOT PARENTS)

Name Relationship Type Work Phone Cell Phone Home Phone
Doctor If a medical emergency exists, the school will take appropriate action on behalf of the child. The family will assume all medical costs.

OTHER SIBLINGS LIVING AT HOME

Name Gender Birthdate School Grade

SECTION SIX

Are you currently attending school?
Are you planning to go back to the last school district attended?

Do you have a GED?

Do you have a high school diploma?
When do you plan on working in your classes?




SECTION SEVEN - DISCLAIMERS

Student Name:

Disclaimer:

Michigan State Required Testing
It is mandatory that students in our program participate in state and federal testing during required dates. Please note that families are also responsible for travel costs associated with commuting to our physical building location(s) for orientation(s), state and federal testing purposes, and any other required activity. Families should consider travel limitations before enrolling at our school.
Is there a court order prohibiting anyone from having contact with the student?
If yes, who is not allowed to have contact with the student?

***NOTE*** The school must have a copy of the order to deny release/contact to a parent.

Please Read: Presenting false information, false records or falsifying records is an offense punishable by federal and state law. By signing below, you attest that all information provided on this form is true and accurate.
Press/Video Release

Step-Up Schools has my permission to use photographs and/or videos of my child to show school activities to the public. I understand that the personally identifiable information may be used at the discretion of the media, involving no financial compensation to Step-Up Schools , the student, or the family of the student. The final edited pictures and sounds may be shown without restriction, including radio and television broadcast, cablecast, printed publication, website and any other social media. I understand that I have the right to deny consent to the release of the photographs and/or information specified above, by refusing to sign this. If you consent, please sign here:
If permission is denied, please write “DENIED” on the signature line
Please Read: Presenting false information, false records or falsifying records is an offense punishable by federal and state law. By signing below, you attest that all information provided on this form is true and accurate.

SECTION EIGHT - POLICY SHEET

As a Step Up Student I understand:
I plan to use my own internet.
FOR OFFICE USE ONLY

Step-Up Student Enrollment Form ONLINE LEARNER READINESS RUBRIC

Name:
Date:

1. My access to technology is best described as:



2. My experience with discussion boards/online bulletin boards (Moodle, Blackboard, etc.) is:



3. My technology skills are best described as:



4. When working with technology:



5. When starting a new school lesson/unit:



6. When I need help in class:



7. When it comes to completing school work:



8. When it comes to reading and writing



9. I think an online class



10.

FILE UPLOADS

Required Documents:

Birth Certificate

Picture I.D.

Proof of Residency (Utility Bill, Lease Agreement)

Shot/Immunization Record

All High School Transcripts

Upload Your Documents

To help expedite your application process, we give you the option to upload digital versions of any or all of these documents onto our secure, encrypted servers.

Once your files are received, they will be removed from the site and stored in our office.

Depending on the district, you may be asked for other documents.

To upload your files, check the boxes above to indicate which documents you are including then select the files on your computer in the popup window after clicking 'Upload Your Documents'

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