Union Alternative Application

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This form needs to be filled out prior to the student being considered for placement at the Alternative School.

Student Name *

Student ID Number (if currently enrolled at Union) *

Who does the student live with currently? *

Both Parents

Mother

Father

Grandparent(s)

Mother/Step-Father

Father/Step-Mother

Other

Contact Number for Student *

Contact Number for Parent or Guardian *

Additional Numbers you would like to leave for the Alternative School to use to contact the student and/or parent?

List an email address where the Parent/Guardian can be reached? *

Who referred you to apply for the Alternative Program? (School Counselor, Principal, friend, relative, etc.)

Why are you applying for the Alternative School? *

What is your educational goal? *

Please check-mark any of the following that you believe has contributed to your problems at school. *

Difficulty in dealing with Authority Figures

Poor Attendance

Falling behind in my studies

Frequent Suspensions

Transportation Problems

Difficulty paying attention in class

Parent's Divorce or other home problems

Boredem

Frequently moving school districts

Chronic Health Problem(s)

Strong dislike of Teachers

Shyness

Pregnancy or child rearing

Truancy

Tardiness

Difficulty in learning the English Language

Drug or Alcohol use

Teachers who don't care about their students

lack of structure in school

Fear of Violence at school

Required

List any medications that the student is taking currently. Type none if not applicable *

To be filled out by Parent/Guardian: What are some of your his/her strengths

To be filled out by Parent/Guardian: What are some of your his/her weaknesses?

To be filled out by Parent/Guardian: In what activities is he/she interested?

To be filled out by Parent/Guardian: What else should the counselors and teachers know about your student?

Union Alternative Student Agreement

1. I agree to attend school regularly. I will be in class and on time consistently. When absences are unavoidable, my Parent/Guardian will contact the attendance office to inform the school of my circumstances. I understand I will not receive credit for any class in which I do not attend at least 80 percent of the class sessions.
2. I agree to participate in classroom activities as my teacher asks.
3. I agree to respect my classmates, my teachers and my school building.
4. I agree not to use/possess tobacco, alcohol or other drugs on school property or while participating in school – related activities. In addition, I will not come to school while under the influence of these substances.
5. I agree not to participate in violence/ threats of violence or to use/possess any type of weapon(s) on school property or while participating in school- related activities.

BY SIGNING BELOW, I UNDERSTAND THE FOLLOWING:
• It is my right to use building facilities outside of the Union Alternative Education area; however, it may be limited in some respects. I am accountable for the same rules as regular education students when I am outside the Union Alternative Education area.
• My continued attendance in the Union Alternative Education Program will be reassessed at the end of each semester.
• I may be involuntarily sent to in-school suspension or returned to regular education of I violate this agreement.

Do you agree to the above student agreement? (by checking one of the below statements, that will suffice as your signature at this time. ) *

Yes I agree

No I do not agree

Submit

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