New 22 Plus Student Self Report Intake Form

First Name *

Last Name *

Date * +

Birth State *

Your Address *

What school did you last attend or should you have attended? *

What other high schools did you attend (in addition to the one listed above)? *

What year do you believe you should have graduated? *

How old would you have been? *

How many credits do you think you may have? *

What graduation test(s) did you not pass? *

Which tests did you pass? *

Will this limit your hours completing your diploma? *

Yes

No

Are you or have you been on probation? *

Yes

No

Are there other issues which may limit your time to earn your diploma? *

Yes

No

Describe what your attendance was like before you dropped out of your last high school: *

On average, what kinds of grades did you think you received on your last report card? *

Were you ever suspended or expelled from any school? *

Yes

No

For how long? *

May we know what happened? This information may help us help you. *

Were you in a free lunch program at your last high school? *

Yes

No

Do you have a copy of your transcript of all of your grades? *

Yes

No

Do you know if you owe school fees to your last school? *

Yes

No

What held you back from doing your best in school? *

Would you like the opportunity to discuss any issues with a trained counselor/social worker in a confidential setting? *

Yes

No

How did you find out about Academy for Urban Scholars High School 22+ Program? *

Academy for Urban Scholars 22+ Adult Diploma Program Registration Form

The following documents are required to complete your registration.

Transcript from the last school attended

Proof of Age ( Example: Birth Certificate or I.D.)

Proof of Residency (Example: Utility bill for the past 30 days)

Your Name *

Birth Certificate Name if Different from Above *

Birth City *

Birth State *

Date of Birth * +

Gender *

What is your primary language? *

Social Security Number *

Phone Number *

Alternate Phone Number *

Emergency Contact And Phone Number (can not be parent) *

Email *

School District Of Current Residence *

Date Residency Began * +

What schools did you last attend? *

Last Year Attended *

First Year in 9th grade? *

Last Grade Completed *

Mothers Maiden Name *

Policies for 22 + program

1. All Students must have birth certificate, social security card, and proof of address to Credits cannot be reported until all enrollment procedures are complete.

2. All Students must schedule class times and will be held responsible to attend school when scheduled unless prior notice is given.

3. All Student musts attend school at least once a week. The only exception is outside Testing and review sessions must take place at school.

4. Attendance hours are reported to the Ohio Department of Education with completed coursework.

5. If student is not in attendance, or if student does not contact the staff for 30 days, they may be disenrolled from the program.

6. Student must have official transcript in order to get credit for previous classes taken at previous schools.

7. Student will be held responsible for completing their own work, and passing a final test for each.

8. Student will be respectful all staff members and other students.

9. Students who were required to pass Ohio Graduation Test or Ohio Proficiency Test when they were originally enrolled in high school will be required to pass the OGT's/Proficiency Test to receive a diploma.

10.IEP's are only applicable for test exemption if they were valid at the original time of graduation. Current testing accommodation must be discussed with your teacher as IEP's are not valid for adult learners unless they have been continuously recertified from an adult support.

AUS 22+ Student Schedule

Please fill in the schedule with the days and times that are ideal for you. You may set your own schedule, but once determined, you need to call in if you will not be present on your designated day. All attendance and calls must be documented. Permanent schedule changes must be made in writing.

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Signature *

clear

Date * +

Administrator Signature

clear

Date +

By signing this form I acknowledge that I have read this form and agree that all information I entered is accurate.

*This form and any response to it may constitute a public record, and therefore may be available upon request in accordance with Ohio public records law (ORC 149.43).