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YOUTH INSTITUTE SUMMER ACADEMY APPLICATION
STUDENT INFO
*
Indicates required field
Name (First and Last)
*
First
Last
Cell Phone Number
*
Email
*
School Name
*
Small School (If Applicable)
*
Click to Select
AC
AHA
AMPS
CAS
ELD
IB
Independent Studies
None of the above
Student ID Number
*
Expected Year of High School Graduation
*
Click to Select
2018
2019
2020
2021
Does the student have any special physical, behavioral and/or learning needs our staff should be aware of? Please explain:
*
Ethnicity
*
Click to Select
African American / Black
East Asian
Hispanic / Latino
Indigenous Group
Middle Eastern
Multi-Racial
Pacific Islander
South / Southeast Asian
White / Caucasian
Other
Total Number of People in Household
*
Family Income
*
Click to Select
Under $20,000
$20,000 to $30,000
$30,001 to $40,000
$40,001 to $50,000
$50,001 to $60,000
$60,001 to $70,000
$70,001 to $80,000
Over $80,000
Does student qualify for free/reduced lunch?
*
Yes
No
Unknown
Parent/Guardian Information
Parent/Guardian 1 Name (First and Last)
*
First
Last
Relation
*
Father, Mother, Etc
Phone Number
*
Text?
*
Yes
No
Parent/Guardian 2 Name (First and Last)
*
First
Last
Relation
*
Father, Mother, Etc
Phone Number
*
Text?
*
Yes
No
Emergency Contact/Child Release Authorization
The YMCA-PG&E Teen Center has my unrestricted permission to release the named minor at any time to the following individuals and to contact them in case of an emergency if the parent(s)/guardian(s) are unavailable:
Name
*
Relation
*
Phone Number
*
Email
*
Name
*
Relation
*
Phone Number
*
Email
*
Participant Health Information
To be completed by parent/guardian. If your child has special needs, please let us know.
Medical Insurance Carrier
*
Dental Insurance
*
Policy Number
*
Policy Number
*
Medicines Currently Taking
*
Known Allergies
*
How did you hear about the Berkeley YI Summer Academy?
*
Family Member
Friend
Teacher
Counselor
Other
Please type the referring person's name:
*
Personal Questions
(We thank you in advance for being open to people you do not even know)
All questions need to be answered by the student.
Based on what you know so far, why do you want to join the Berkeley YI Summer Academy?
*
Tell us about your experience(s) in storytelling, digital media, or any other forms of art.
*
What would you say makes you "You"? What are unique aspects and/or talents that you have learned about yourself?
*
Please tell us a tough personal challenge you have had to overcome or are currently fighting. What did you do or are currently doing?
*
BERKELEY YOUTH INSTITUTE SUMMER ACADEMY COMMITMENT CONTRACT
Summer Academy Schedule Commitment
I will attend all classes in the Summer Academy (July 10th-August 17th, Mon-Thur, 1-6pm)
*
Yes
No
We (student and family) will be able to attend the Summer Academy Graduation (August 19th, 6-8pm)
*
Yes
No
Summer Academy Attendance and Effort Commitment
Student and parent/guardian, please read these statements below, check each box to agree to each statement.
I (student) will make an attendance and effort commitment to the Berkeley TI Summer Academy by doing the following:
*
I will show up on time and actively participate in all programming.
I will complete all tasks assigned by the deadlines set by the YI Staff.
I will treat all staff and students with respect and mindfulness.
I will use all Teen Center equipment and furniture with care.
I will have no more than 2 absences (2 tardies=1 absence)
I will meet with staff to discuss any issues or incidents that happen during the Summer Academy
As a parent or guardian:
*
I am committed to paying for any equipment and property damage if the YI staff determines that the student did not handle the equipment and property with care.
I am committed to attending the Summer Academy orientation, family meetings, graduation, and any other family activities when my attendance is required and requested.
Submit
Home
About
Our WHY
Our CULTURE
Our TEAM
Y-Scholars
Membership
Alumni
>
Update Contact Information
Alumni FAQ
Events
College Mindset Academy
>
CMA Application
Get Involved
Jobs
>
Positions
Volunteer
>
Senior Advisor
Partnerships
DONATE
