Returning Student Application    
This application is for returning students interested in becoming apart of the 2022-23 Step Up cohort.

If you have any questions about this application please contact the Student Success Specialist, Site Supervisor, and/or Advocate who has been in contact with you at your specific high school.
Sign in to Google to save your progress. Learn more
Statement of Confidentiality:
It is the policy of all Open School programs that all information received regarding an applicant's application for admission will be treated with complete confidentiality. Only authorized Step Up school personnel have access to such information and then only to the extent that the information is relevant to admission and placement decisions. Information received within the scope of this policy is not disclosed to the applicant or the applicant's family.
Notice of Non-Discriminatory Policy:
Open School programs do not discriminate against any person with respect to employment or provision of services on the basis of race, color, national and ethnic origin, gender, sexual orientation, age, religion, class, marital status, political affiliation, disability, veteran status or any other category prograted by applicable law. Open School does not discriminate on these bases in the administration of any activities.
Student Information:
Enrolled High School *
Grade Level *
Required
Student Name *
Student's preferred name and/or nickname? (What we'll call you when referring to you.)
PPS ID:
Date of Birth: *
MM
/
DD
/
YYYY
Please list all of your previous Step Up Advocates:
Student Demographics
The following questions help us to better serve our returning students.
Gender: *
Required
Pronouns: *
Required
Race and Ethnicity *
Required
Student's Current Residence:
Who does the student live with? *
Relationship(s) to student: *
Address: *
City: *
Zip Code: *
Student's Cell:
Main Home Phone: *
Student's Email:
What is the best way for our staff to communicate with you? *
Required
Parent/Guardian Information:
Name of Parent/Guardian *
Relationship to student: *
Address (feel free to state "Same as student"): *
City: *
Zip Code: *
Cell/Main Phone: *
2nd Phone:
Work Phone:
Email Address:
What is the best way for our staff to communicate with you? *
Required
What is the best week day for our staff to reach you?
Clear selection
When is the best time of day for our staff to reach you?
Clear selection
Additional Parent/Guardian Information (if applicable):
Parent/Guardian Name:
Relationship to student:
Address:
City:
Zip Code:
Main Phone:
2nd Phone:
Work Phone:
Emergency Contact Information:
Name of Emergency Contact: *
Relationship to student: *
Main phone: *
2nd Phone:
Student Information Continued:
Has your student been assessed as eligible for Special Education Services? *
Is your student eligible for Free/Reduced Lunch? *
Communications:
Important Family Questionnaire
Some Step Up activities may pose a challenge to our youth and have the potential to generate an intense response. Therefore, the more information provided regarding your student's ability to cope with stress, the better our ability to care for them and keep them safe. For this reason, we ask that you volunteer some or all of the following information.
In the recent past, our family has dealt with:
Our family is houseless or experiencing housing issues: *
If you answered "Yes" to the last question, please describe:
May we contact you regarding the information you provided should we have any additional questions? *
Electronic Signature Consent Statement
This statement refers to the following: "Authorization to Provide Treatment"; "Field Trip Permission Form"; "Release of Student Information"; "Electronic Image/Photo Release Statement"

By checking below, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature.
Electronic Signature Consent Agreement: *
Required
Medical Information
Information collected in this document is to ensure we are equipped to handle any incident that may occur while your student is under Step Up supervision. Please use your discretion in completing this form.
Allergies: Please identify any allergies to foods, drugs, insect bites, dust, etc., and give the nature of the reaction(s): *
Medications: Please list any medications that will need to be taken during Leadership Camp, Field Trips, etc. (include medication name, dosage, frequency, and whether or not the student needs assistance in administering said medication): *
Injuries and/or Disabilities: Describe any disabilities, such as injuries, surgery, broken bones and/or sprains which might limit participation during certain activities. *
Communicable Diseases: Please list any known infections and/or diseases which are transmissible directly from one person to another (if any):
Common Conditions: Please check all that apply: *
Required
If you checked the box "Special dietary needs" please provide more details:
Please list any other medical conditions not listed above:
Medical Treatment
In the event of an injury the Step Up Program of Open School Inc. will make every effort to contact the parent/guardian prior to treatment. In a situation in which effort to make contact with the parent/guardian is unsuccessful, treatment for the injury will be pursued.
Authorization to Provide Treatment
As a parent/legal guardian of my student, I authorize Open School staff to assume care and responsibility of my student while on field trips associated with Open School and during the course of the Open School program. This authorization is applicable throughout my student's involvement with the Step Up program.

I hereby grant authority for my student to receive emergency treatment/care of a legally qualified doctor, dentist, and/or hospital when it is deemed necessary or in my students' best interest.

In the event that emergency medication is needed, i.e. Epi Pen, inhaler, or other prescription medications, Open School staff has permission to transport my student to the nearest licensed medical professional to administer medication as directed, unless I provide specific permission (see below)*

I hereby release Open School from any responsibility for any expenses which may be incurred in providing emergency, dental, or medical treatment.
Do you agree to the above "Authorization to Provide Treatment"? *
Required
Permission to Administer Specific Medication
In the case of an emergency in which your student cannot be transported to the nearest licensed medical professional in a timely fashion, you may give consent to an Open School staff member to administer the specific form of medication below by checking the appropriate box and agreeing to this release.
I consent to an Open School Staff member to administer the specific form of medication below to my student: *
Please provide an electronic signature by typing out your name as the legal parent/guardian of the applicant: *
Field Trip Permission Form
Please read through this entire section, if there is anything about this section or the described activities that you do not understand please let us know. Read carefully and make sure you understand each detail before signing.
It is the practice of Open School programs to keep students and parents/guardians safe during educational experiences. In travelling off school property, additional opportunities are offered only if parents/guardians agree their student may participate despite potential increased risk.
- The dangers which are present in these trips are those commonly experienced by and known to all persons traveling with young people within the United States. Open School cannot and does not claim to control such dangers. Parents and participants wishing more information regarding the trip and its leadership should contact the Program Director.

- Parents are responsible for determining whether their student has the ability to participate based on behavior and maturity level, given all information provided. Students must have the ability to accept direction and participate responsibly and safely.

- Field trips are a part of the program and may occur with little or no advance notice. In some cases, transportation for field trips may be provided by a staff member trained and certified to provide transportation in an Open School vehicle or common carrier.

- Off-site activities such as overnight camps, challenge, or ropes courses, include known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to participants. Such risks cannot be eliminated without jeopardizing the essential qualities of the activity. The risks include, among other things: the hazards of traversing uneven terrain and slips and falls; the use of climbing ropes and equipment; the risks of exposure to insect bites; a student’s physical condition, and the physical exertion associated with this activity.
Field Trip Permission Statement
I hereby release and agree to defend and hold harmless Open School Inc, its officers, agents, and employees, including the Program Director and their assigns, from any claims by any person, entity or estate, in any forum that may arise against them by reason of property loss or injury and/or death resulting from any cause including, but not limited to, the student or other students having failed to properly carry out instructions from Open School employees.

I give permission for my student to participate in field trips organized by the Step Up Program of Open School Inc. for the duration of time that they are enrolled in Step Up.

I acknowledge I have the authority to agree to and grant this release.
Do you agree to the above "Field Trip Permission Statement"? *
Please provide an electronic signature by typing out your name as the legal parent/guardian of the applicant: *
Returning Student Questionnaire:
Answering these questions will help us make sure you get placed with the advocate that will be set-up to best support you.

Take time to reflect on your Step Up experience so far.

What would you like us to know and take into consideration?

Please be honest and provide as much information as you'd like.
What kind of programming have you participated in? *
Required
What kind of programming would you like to see more of? *
Required
What are three things you gained from Step Up last year? *
What would you like your next Advocate to know about you? *
What do you need from your next Advocate? *
Thank you!
Please read below for the next steps:

Once your application has been submitted in the coming weeks the Student Success Specialist, Site Supervisor, and/or Advocate who has been in contact with you from your specific high school will be in touch with you.

If your student is not re-enrolled into our program it is likely that they may be placed on a waitlist, if that is the case we will do our best to update you and your student.

If at anytime you would like to withdraw your student's application to our program for any reason, please let us know!
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Open School. Report Abuse
Google Forms