Shared Instruction Registration Form

Please complete the form below. Required fields marked with an asterisk *

Student Information for SHARED INSTRUCTION YABC

Student ID Number*

Answer Required

Student Last Name*

Answer Required

Student First Name*

Answer Required

Student Home School Email*

Answer Required

Student Street Address*

Answer Required

Student City, State, Zip Code

Answer Required

Student Home Phone Number*

Number Required

Student Cell Phone Number*

Number Required

Home School Counselor Name*

Answer Required

Home School Counselor Email Address*

Answer Required

Home School Counselor Contact Phone Number*

Number Required

Parent/Guardian consent is required for students younger than 18. If the student you are registering today is younger than 18, have you contacted the parent/guardian about YABC and have they given their consent for the student to attend? *

Answer Required

The student is 18 or older and parental consent is not required.

The student is younger than 18 and I have contacted the parent/guardian.

The student is younger than 18 and I have not contacted the parent/guardian. (Please do not submit the application until you have contacted the student’s parent/guadian

Please check all that apply:*

Answer Required

IEP - Student has a current IEP

ENL - Student is eligible for ENL services

504 - Student has a current 504

None

What is the student's ENL level?*

Answer Required

The student does not receive ENL services

Entering

Emerging

Transitioning

Expanding

Commanding

DBK Initials 1

Shared Instruction Courses

Does the student need English Classes?*

Answer Required

Student does not need an English Class

English 1

English 2

English 3

English 4

English 5

English 6

English 7

English 8

Does the student need history classes?*

Answer Required

Student does not need a history class

Global 1

Global 2

Global 3

Global 4

US history 1

US history 2

Participation in Government

Economics

Which math courses does the student need?*

Answer Required

Student does not need a math class

Algebra 1 term 1

Algebra 1 term 2

Geometry 1 term 1

Geometry 1 term 2

Advanced algebra term 1

Advanced algebra term 2

Which science courses does the student need?*

Answer Required

Student does not need a science class

Living Science term 1

Living Science term 2

physical science term 1

physical science term 2

Which art/music, LOTE, health, and/or PE courses does the student need?*

Please check all that apply

Answer Required

Student does not need a class for art, music, LOTE, health, or PE

art/music term 1

art/music term 2

LOTE term 1

LOTE term 2

Health

PE .05 credits

Additional PE .05 credits

Is there anything else you'd like to tell us about the student or add any notes about the student's course requests? If yes, please add note below:

Answer Required

Student's current schedule in day school*

Answer Required

Choose a file or drag it here.

My school's Principal/Admin has approved this student's participation in the YABC's Shared Instruction track..*

All shared students' enrollment in YABC must be approved by the sending school principal or admin in advance.

Answer Required

Yes

Shared Instruction Documents to Submit

Student's S-1 Form*

Answer Required

Choose a file or drag it here.

Student's S-2 Form*

Answer Required

Choose a file or drag it here.

Student's Permanent Record*

Answer Required

Choose a file or drag it here.

Student's IEP/504 Form

Answer Required

Choose a file or drag it here.

Please report to George Westinghouse Campus the following school day to complete registration. Our address is 105 Tech Place, Brooklyn NY 11201.

Please fix the highlighted areas below before submitting.

Shared Instruction Registration Form