2023-24 Flushing YABC Intake Request Form

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Guidance Counselors: Please complete this form for each student you recommend to Flushing YABC.

In addition, please email the Y1/Y2 (for full time enrollment) or S1/S2 (for shared instruction), current permanent record, ATS RISA, and IEP (when applicable) to all three of these addresses:

jpetty@schools.nyc.gov; tcrossman@schools.nyc.gov; mpichardo9@schools.nyc.gov

Complete instructions and Y1, Y2, S1 & S2 forms can be found on our website, www.flushingyabc.org, under "About YABC>Registration Information."

Last Name of Student *

First Name of Student *

OSIS Number *

Sending School Name *

Sending School DBN *

Sending Counselor Name *

Sending Counselor Email Address *

Student DOB *

YYYY

Student Phone No. *

Student Email Address *

Parent/Guardian Name *

Parent/Guardian Email or Phone No *

Is this a full-time transfer or a shared instruction request? *

Full Time

Shared Instruction

Check all that apply *

IEP: Student has a current IEP

ENL: Student is currently eligible for ENL services

504: Student has a current 504

None of the above

Required

Student's preferred pronouns (Check all that apply) *

She/Her/Hers

He/Him/His

They/Them/Theirs

None of the Above (Please write in additional info below if applicable)

Required

Thank you for referring your student to Flushing YABC. Please add any additional information you think our staff should know prior to the interview. (Optional)

Submit

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