Submitted by hawiw@reapusa.org on Thu, 09/01/2022 - 23:28 Select programs you are applying to - Select -SolutionsReflectionsRenaissanceYoung Entrepreneur ProgramJourney AcademySojourn Which Journey Academy course are you registering for? NABlack Studies ClassEntrepreneurship & BusinessComputer Coding Class Student Information Student ID First Name Last Name Birth Date Gender - Select -FemaleMaleOtherTransgenderGenderqueerNon-binaryGender Other Grade - Select -Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th What is the students gender identity? Country United States Street Address Street Name City State Zip Code County Student Enrollment Fields Student Personal Email Students Phone Number Name of Student's School - Select -Centennial DistrictHarold Oliver SchoolParklane Elementary SchoolCentennial Middle SchoolCentennial High SchoolDavid Douglas DistrictRon Russell Middle SchoolDavid Douglas High SchoolAlice Ott Middle SchoolFloyd Light Middle SchoolPortland Public School DistrictBeach Elementary SchoolLane Middle SchoolKellogg Middle SchoolMt.Tabor Middle SchoolBeaverton School DistrictAloha High SchoolBeaverton High SchoolMt. View Middle SchoolMeadow Middle SchoolLevi Anderson Alternative SchoolNorth Clackamas School DistrictMilwaukie High SchoolSt. Helens School DistrictSt. Helens High SchoolPlymouth High SchoolSt. Helens Middle SchoolTigard Tualatin School DistrictTuality Middle SchoolFowler Middle SchoolGresham BarlowGresham High SchoolN/AOther Name of Student's School Other Student's Ethnicity Student's Race - Select -Latino/HispanicAfrican American/BlackNative American/Alaska Native/IndigenousNative Hawaiian/Pacific IslanderAsianSlavicMiddle EasternMultiracialWhiteOther Race Other Student of Hispanic or Latino descent? YesNo Language spoken at home Preferred Language ArabicRussianUkrainianVietnameseEnglishFrench Spanish Student's Dietary Restrictions - Select -VegetarianVeganGluten FreeLactose IntoleranceOtherNone Dietary Other Emergency Contact First Name Emergency Contact Last Name Emergency Contact Phone Number Does student have any food allergies? YesNo List food allergies if any Is there any student medical information REAP should be aware of? YesNo Please list other medical information Does student have a disability that requires accommodations? YesNo Please list accommodation requests Medical Insurance Company Insurance Policy Number Pre-Enrollment Survey Was the student involved in REAP last year? YesNo Thinking back to last school year, how many days did the student miss school? Never1 day2-5 days6-14 days15-20 days What were the student's grades last year? Mostly A'sMostly BsMostly C'sMostly DsMostly F's How did the student feel about attending school? 1 = dislike2 = somewhat dislikeneutral4 = somewhat like5 = like How many suspensions did the student have last year? None1-23-56-10More than 10 How many referrals did the student receive last year? None1-23-56-10More than 10 Was the student involved in after school activities last year? YesNo Was the student in any leadership positions last year? YesNo How confident is the student about their current study habits? 1 = not confident at all2 = somewhat confident3 = neutral4 = fairly confident5 = extremely confident How comfortable is the student in front of a group of their peers? 1 = very uncomfortable2 = slightly uncomfortable3 = neutral4 = fairly comfortable5 = extremely comfortable How comfortable is the student with their identity? 1 = very uncomfortable2 = slightly uncomfortable3 = neutral4 = fairly comfortable5 = extremely comfortable How supported does the student feel by their family? 1 = not supported at all2 = slightly supported3 = neutral4 = fairly supported5 = extremely supported How comfortable is the student when presenting thoughts and ideas to others? 1 = very uncomfortable2 = slightly uncomfortable3 = neutral4 = fairly comfortable5 = extremely comfortable How supported does the student feel by their group of friends? 1 = not supported at all2 = slightly supported3 = neutral4 = fairly supported5 = extremely supported How supported does the student feel by their teachers? 1 = not supported at all2 = slightly supported3 = neutral4 = fairly supported5 = extremely supported Does the student need support in any of the following areas? Academic PerformanceSelf-EsteemFamily SupportBehavioral SupportStudy HabitsCivic EngagementSchool Attendance and PerformanceSocial SkillsCareer ReadinessLeadership OpportunitiesCollege/Trade School PlanningMental HealthPhysical HealthOther List other support needed What are the student's goals for the upcoming year? What are the student's hobbies? What are the student's future career plans? What does the student hope to gain by being a part of REAP this academic school year? Student's T-Shirt Size - Select -XSSMLXLXXL Is the student involved in the Juvenile Justice System? YesNo What is the parent's total annual household income? - Select -Less than $19,000$20,000 to $34,999$35,000 to $49,999$50,000 to $74,999$75,000 to $99,999More than $100,000Unemployed Does the student qualify for free or reduced lunch? YesNo Does the student use public transit to and from school? YesNo Does the student receive services from the Oregon Department of Human Services? YesNo Is the student involved in the following organizations? If yes, please select all that apply. SEIStep UpPOICNAYA Parent Information First Name Last Name Phone Number Email Please read the statement and select one of the following - Select -I have read the statement below and confirmI have read the statement and DO NOT confirm Release of Information & Publication/Liability By signing the box below, I understand that I am authorizing REAP employees to have access to my child’s school records in order to perform program services. In addition, I hereby give my consent for any medical treatment or hospitalization that might become necessary for my child and agree to take full financial responsibility for such care. I hereby fully and forever waive and release REAP, its directors, staff or volunteers from and against any and all claims, demands, losses, liabilities, damages, actions, causes of action, suits, judgments, costs, and expenses (including courts or attorney fees) in any way whatsoever arising out of or relating to my child’s participation in REAP. Please sign here Sign above Release of Publication Liability Signature By signing this section of the form, I am authorizing the release for publication of any photos, film, or videotape of my child participating in REAP activities. You always have the option for you or your family to opt out of marketing photos and videos published by REAP. Sign here Sign above Virtual Phone Engagement Recording Waiver As REAP transitions its program offerings to a video chat platform, our organization is taking simple and clear precautions to make sure that all of our interactions remain empowering, constructive, and supportive. As a non-profit Community Based Organization (CBO), we value our partnerships with school districts to collaborate and support students in times of crisis. With school-building procedures adapting during this time, REAP wants to maintain our offerings of trauma-informed and restorative based practice, honor the confidentiality of every student, and ensure that student needs are met equitably and responsibly. As a best practice going forward, the REAP organization will be recording and archiving all virtual interactions from start to finish with this purpose: 1. REAP will archive all REAP one-on-one, small group, and larger group video chat sessions. This video footage will not be shared outside of the organization without explicit written consent. REAP will only use video footage in case of safety concerns regarding a REAP student or if grievances occur around misconduct from a REAP student or staff. 2. If given consent through the REAP Enrollment Form, REAP may use brief clips of group and one-on-one engagement for REAP marketing materials. These interaction clips will not reveal any personal information about REAP students or sensitive group discussion, and any student who does not wish to be included will be blurred out or omitted entirely from any video marketing. Additionally, we always encourage all REAP students to invite their parents to engage during one-on-ones, especially for younger REAP leaders. When you sign below, you agree to your student being recorded in photo and video format. REAP will never use recorded media without a student and family’s consent. Sign here Sign above Date of Signature Submit