"Keystone State Challenge Academy Student Application" - Pennsylvania

Keystone State Challenge Academy Student Application is a legal document that was released by the Pennsylvania Department of Military and Veterans Affairs - a government authority operating within Pennsylvania.

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Return completed applications to:
Email: RA-MVPACHALLENGE@pa.gov
or
Mail: Keystone State Challenge
Academy
Attn: Admissions
BLDG 0-13A
Fort Indiantown Gap
Annville, PA 17003
Thank you for your interest in the Keystone State ChalleNGe Academy.
Please complete all signatures using the digital signature (if able) or physically sign and date as indicated.
Section 1: Applicant Information
Last Name
First Name
Middle Name
Preferred Name
Gender
Birthdate (mm/dd/yyyy)
Applicant Address Line 1
Applicant Address Line 2
City
State
Zip
Applicant Phone Number
Applicant Email
Preferred Contact Method
Best Time to Contact
Email
Phone Call
Text Message
Mail
Section 2: Parent/ Legal Guardian Information
Last Name
First Name
Authorized to Pick Up from Academy
Yes
No
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Email
Relationship to Applicant
Parent
Legal Guardian
Other (Please Explain)
Section 3: Alternate Emergency Contact
Last Name
First Name
Authorized to Pick Up from Academy
Yes
No
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Email
Relationship to Applicant
Parent
Legal Guardian
Other (Please Explain)
Return completed applications to:
Email: RA-MVPACHALLENGE@pa.gov
or
Mail: Keystone State Challenge
Academy
Attn: Admissions
BLDG 0-13A
Fort Indiantown Gap
Annville, PA 17003
Thank you for your interest in the Keystone State ChalleNGe Academy.
Please complete all signatures using the digital signature (if able) or physically sign and date as indicated.
Section 1: Applicant Information
Last Name
First Name
Middle Name
Preferred Name
Gender
Birthdate (mm/dd/yyyy)
Applicant Address Line 1
Applicant Address Line 2
City
State
Zip
Applicant Phone Number
Applicant Email
Preferred Contact Method
Best Time to Contact
Email
Phone Call
Text Message
Mail
Section 2: Parent/ Legal Guardian Information
Last Name
First Name
Authorized to Pick Up from Academy
Yes
No
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Email
Relationship to Applicant
Parent
Legal Guardian
Other (Please Explain)
Section 3: Alternate Emergency Contact
Last Name
First Name
Authorized to Pick Up from Academy
Yes
No
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Email
Relationship to Applicant
Parent
Legal Guardian
Other (Please Explain)
Section 4: Applicant Mandatory Eligibility Requirements
YES
NO
Please answer “Yes” or “No” to the following questions
Will you be between the ages of 16-18 on the first day of the Academy?
Are you a US Citizen/Lawful Permanent Resident and a resident of Pennsylvania?
Have you received a high school diploma or General Equivalency Degree (GED)?
Are you a high-school drop-out or at risk of not graduating on-time?
Have you been ticketed, arrested, or detailed for any offense by any law enforcement agency?
Are you awaiting sentencing or have any future court dates to resolve pending charges?
Are you currently on probation?
Are you willing to be free from the use of illegal drugs/ alcohol and/or illegal substances during the Academy?
Are you physically and mentally capable of participating in the Academy?
Section 5: Household Information
YES
NO
Please answer “Yes” or “No” to the following questions
Are you married?
Do you have children?
If “Yes”, how many? ___________________
Are you in foster care?
Are you homeless or at-risk of becoming homeless
Who do you live with?
How many people live in the house (including yourself)
Is a language other than English spoken in your home?
Language:
Yes
No
Do you communicate in a language other than English?
Language:
Yes
No
What is the first language that you learned to speak?
Section 6: Employment Information
YES
NO
Please answer “Yes” or “No” to the following question
Are you currently employed?
Number of Hours Per Week
Employer
Hourly Rate
Section 7: Additional Applicant Information
YES
NO
Please answer “Yes” or “No” to the following questions
Do you smoke/vape and/or use tobacco products?
Have you ever consumed alcohol or been drunk?
Have you ever used illegal drugs or abused prescription drugs?
Have you ever been treated or hospitalized for drug use?
Have you had periods of depression, attempted suicide, or seriously considered suicide?
Are you a member of, or affiliated with a gang?
Section 8: Educational Information
YES
NO
Please answer “Yes” or “No” to the following questions
Do you have an Individualized Education Plan (IEP) or a Section 504 Service Agreement
Have you ever been suspended from school?
Have you ever been expelled from school?
Are you habitually truant from school?
Section 9: Applicant Goals and Personal Statement
Please select all that apply
Earn/recover high school credit
Return to your home school and graduate with a diploma
Earn a Graduate Equivalency Degree (GED)
Enroll in a vocational training program
Achieve a personal sense of accomplishment, self-
Explore careers
esteem, and discipline
Gain job skills for employment
Learn about and apply for college(s)
Other:
Please write a personal statement to help us get to know you. Tell us why you want to attend the Academy, what you hope to achieve, and
how you believe this experience will help you accomplish your educational and career goals.
By signing below, you ensure to the best of your knowledge, all information provided is true and accurate.
Applicant Signature
Parent/Legal Guardian Signature
Printed Name
Printed Name
Date
Date
SEE BACK OF FORM FOR RELEASE OF INFORMATION THAT MUST BE COMPLETED
Authorization to Release Information
I hereby authorize the Commonwealth of Pennsylvania, its counties, its cities, and its agencies to submit and/or exchange all pertinent
information with the Keystone State Challenge Academy (KSCA) regarding, but not limited to, the following: substance abuse history,
referral history, court status, family or social services interventions, documented medical conditions, and any other information requested
by the KSCA relevant to the health, safety, welfare, and quality of life of the student/applicant.
I understand that these records are protected under federal and/or state laws/regulations and cannot be disclosed without my written
consent, unless otherwise provided for in the regulations. KSCA is in compliance with the most prominent of the federal protections for
participant privacy including the Family Educational Rights and Privacy Act (FERPA). FERPA protects the confidentiality of student records
to some extent, while giving students the right to review their own records.
I also understand that I may revoke this consent at any time, except to the extent that action has been taken, and that in any event, this
consent automatically expired thirty-six (36) months from the date the application is accepted, and the Applicant has been officially
registered as a student at the KSCA.
Applicant Signature
Applicant Printed Name
Date
Parent/Legal Guardian Signature
Parent/Legal Guardian Printed Name
Date
Family Education Rights and Privacy Act (FERPA) Acknowledgement
It is the policy of KSCA to release Applicant/Cadet (Cadet) information, records, and files, in accordance with the Family Education Rights
and Privacy Act of 1974 (FERPA). The FERPA requires KSCA to provide “advance” information to parents/guardians (parents) and Cadets
18 years-of-age or older, regarding information the Program will release about Cadets and to whom. The following information/records
will be released, in accordance with FERPA, under the following circumstances:
1) To other school officials, including teachers, who have legitimate educational interests in the information.
2) Officials of other schools that the Cadet seeks to enroll in, as long as the Cadet is notified of the transfer of documents and has the
opportunity to challenge the content.
3) Representatives of Office of the Attorney General and the Department of Education.
4) State or local officials, if the disclosure concerns the juvenile justice system and its ability to serve the Cadet, prior to adjudication,
as long as officials certify in writing that the officials will not release the information to others.
5) Accrediting/auditing organizations.
6) Parents of a dependent Cadet.
7) Appropriate persons in health and safety emergencies.
8) A person designated in a lawfully issued subpoena, as long as the educational agency makes a reasonable attempt to contact the
parents before complying with the subpoena.
9) KSCA must disclose, to the maximum extent possible, Cadet information to:
a.
Law enforcement agencies, youth protective services, and health care professionals, in connection with a health and/or
safety emergency, if the information is necessary to protect the Cadet.
b.
Courts and state/local juvenile agencies, if related to the courts/agency ability to serve the needs of the Cadet prior to
adjudication. Persons receiving information must certify in writing that the information will not be disclosed.
10) Mentors designated by the Cadet and approved by KSCA, will receive a copy of the Cadet Post-Residential Action Plan (PRAP)
which may contain various scores and results from the Cadet’s attendance at KSCA, along with the names and addresses of the
Cadet and his/her parents. All mentors receive training and sign an agreement to comply with FERPA confidentiality.
By your signature below, you acknowledge and authorize the release of information and that you have been provided advance notice
under FERPA. Due to the nature and structure of the KSCA, you are giving your consent that we display and give verbal announcements of
scores, grades, and results of assignments, packets, projects, and tests, within the constraints of the classrooms, living, and work areas.
You are encouraged to review the FERPA law if you have any questions or want additional information regarding your rights.
Applicant Signature
Applicant Printed Name
Date
Parent/Legal Guardian Signature
Parent/Legal Guardian Printed Name
Date
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