BYA Program Application

Today's Date (MM/DD/YYYY)

PROGRAM REGISTERING FOR:

Please select... Career Development Center (CDC) for Ages 14-24? Counseling Center for Ages 6-21 +Family Extended Care Programs (Afterschool Center, 1st-8th Grade)? Gardening/Green Pathways for Ages 14-24? Health and Nutrition Programs for Ages 5-24? Sports and Fitness for Ages 5-14? Summer Program for Ages 6-12? Wahkan Substance Use Prevention Program 18-24? Youth Suicide Prevention Program Ages 5-25 + Family Mentoring, Academic Support, Trainings, College Prep, & Health (MATCH) (6th-12th grade) Teen Night (9th-12th grade)

Other:

PARTICIPANT INFORMATION

First Name

MI

Last Name

Drivers/ School/ State ID #

Address Line 1

Address Line 2

City

Country

Please select... Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Postal Code

Phone

Date of Birth (MM/DD/YYYY)

Are You/Your Child enrolled in Medi-Cal?

Please select... Yes No Not Sure

Are You Experiencing Food Insecurity?

YesNo

Gender

Please select... Male Genderqueer/Non-Binary Female Decline to State

Sexual Orientation (optional; choose all that apply): 

Please select... Asexual Bisexual Gay Straight (Heterosexual) Lesbian Pansexual Queer Questioning or unsure same-gender loving an identity not listed prefer not to disclose

You selected 'an identity not listed' please specify below

Ethnicity: Hispanic/Latino/a?

YesNo

Race: (Check all that apply)

Black/African AmericanAsianAmerican Indian/Alaskan NativeWhiteNative Hawaiian/Other Pacific IslanderOther or Multiracial

School

Please select... 1-Other ACORN WOODLAND ELEMENTARY SCHOOL ALLENDALE ELEMENTARY SCHOOL ALLIANCE ACADEMY BELLA VISTA ELEMENTARY SCHOOL BERKELEY ARTS MAGNET AT WHITTIER (BAM) BERKELEY HIGH SCHOOL BERKELEY TECHNOLOGY ACADEMY BRET HARTE MIDDLE SCHOOL BRIDGES ACADEMY BROOKFIELD ELEMENTARY SCHOOL BURCKHALTER ELEMENTARY SCHOOL CARL B. MUNCK ELEMENTARY SCHOOL CASTLEMONT HIGH SCHOOL CHABOT ELEMENTARY SCHOOL CLAREMONT MIDDLE SCHOOL CLEVELAND ELEMENTARY SCHOOL COLISEUM COLLEGE PREP ACADEMY COMMUNITY DAY SCHOOL COMMUNITY UNITED ELEMENTARY SCHOOL CRAGMONT ELEMENTARY CROCKER HIGHLANDS ELEMENTARY SCHOOL DEWEY ACADEMY EAST OAKLAND PRIDE ELEMENTARY SCHOOL EDNA BREWER MIDDLE SCHOOL ELMHURST COMMUNITY PREP SCHOOL EMERSON ELEMENTARY EMERSON ELEMENTARY SCHOOL ENCOMPASS ACADEMY ESPERANZA ELEMENTARY SCHOOL FRANKLIN ELEMENTARY SCHOOL FRED T. KOREMATSU DISCOVERY ACADEMY FREMONT HIGH SCHOOL FRICK IMPACT ACADEMY FRUITVALE ELEMENTARY SCHOOL FUTURES ELEMENTARY SCHOOL GARFIELD ELEMENTARY SCHOOL GATEWAY TO COLLEGE AT LANEY COLLEGE GLENVIEW ELEMENTARY SCHOOL GLOBAL FAMILY SCHOOL GRASS VALLEY ELEMENTARY SCHOOL GREENLEAF ELEMENTARY SCHOOL HILLCREST ELEMENTARY SCHOOL HOOVER ELEMENTARY SCHOOL HORACE MANN ELEMENTARY SCHOOL HOWARD ELEMENTARY SCHOOL INTERNATIONAL COMMUNITY ELEMENTARY SCHOOL JEFFERSON ELEMENTARY JOAQUIN MILLER ELEMENTARY SCHOOL JOHN MUIR ELEMENTARY KAISER ELEMENTARY SCHOOL LA ESCUELITA ELEMENTARY SCHOOL LAUREL ELEMENTARY SCHOOL LIFE ACADEMY LINCOLN ELEMENTARY SCHOOL LONGFELLOW MIDDLE SCHOOL MADISON PARK ACADEMY PRIMARY MADISON PARK ACADEMY SECONDARY MALCOLM X ELEMENTARY MANZANITA COMMUNITY SCHOOL MANZANITA SEED MARKHAM ELEMENTARY SCHOOL MARTIN LUTHER KING JR. MIDDLE SCHOOL MARTIN LUTHER KING, JR. ELEMENTARY SCHOOL (PK-3) MCCLYMONDS HIGH SCHOOL MELROSE LEADERSHIP ACADEMY METWEST MLK / LAFAYETTE ELEMENTARY SCHOOL (4-5) MONTCLAIR ELEMENTARY MONTERA MIDDLE SCHOOL NEW HIGHLAND ACADEMY OAKLAND HIGH SCHOOL OAKLAND INTERNATIONAL HIGH OAKLAND SOL OAKLAND TECHNICAL HIGH SCHOOL OXFORD ELEMENTARY PARKER ELEMENTARY SCHOOL PERALTA ELEMENTARY SCHOOL PIEDMONT AVENUE ELEMENTARY SCHOOL PLACE @ PRESCOTT RALPH J. BUNCHE HIGH SCHOOL REACH ACADEMY REDWOOD HEIGHTS ELEMENTARY SCHOOL RISE COMMUNITY SCHOOL ROOSEVELT MIDDLE SCHOOL ROOTS INTERNATIONAL ACADEMY ROSA PARKS ELEMENTARY RUDSDALE CONTINUATION SANKOFA ACADEMY SEQUOIA ELEMENTARY SCHOOL SKYLINE HIGH SCHOOL SOJOURNER TRUTH INDEPENDENT STUDY STREET ACADEMY SYLVIA MENDEZ ELEMENTARY SCHOOL THINK COLLEGE NOW ELEMENTARY SCHOOL THORNHILL ELEMENTARY SCHOOL THOUSAND OAKS ELEMENTARY UNITED FOR SUCCESS URBAN PROMISE ACADEMY WASHINGTON ELEMENTARY WEST OAKLAND MIDDLE SCHOOL WESTLAKE MIDDLE SCHOOL WILLARD MIDDLE SCHOOL

Grade

Please select... Pre-Kindergarten Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Some Highschool Highschool Graduate Some College College Graduate Other

MEDICAL HISTORY AND COVERAGE

NAME OF FAMILY DOCTOR

Phone

HEALTH INSURANCE PROVIDER

INSURANCE ID #

HAS THE PARTICIPANT COMPLETED THE FOLLOWING?

Chicken Pox Shots

Please select... YES NO

Mumps Shots

Please select... YES NO

TB Test Shots

Please select... YES NO

Tetanus Booster Shots

Please select... YES NO

German Measles Shots

Please select... YES NO

Please select the Covid Vaccine(s) received below

1st Dose2nd DoseBoosterNone

DOES THE PARTICIPANT HAVE

Asthma

Please select... YES NO

Vision Problems

Please select... YES NO

Hearing Problems

Please select... YES NO

Speech Problems

Please select... YES NO

DOES THE PARTICIPANT HAVE ANY OF THE FOLLOWING ALLERGIES?

Food

Please select... YES NO

Insect Bites

Please select... YES NO

Medications

Please select... YES NO

Plants

Please select... YES NO

Other Allergies not listed above, please specify

Special Health Needs

Adult(s) Living with Participant Contact Details

Parent/Guardian (Primary)

First Name 

Last Name

Daytime Phone

Cell Phone

Email

Relationship with Participant

Please select... Mother Father Aunt Uncle Grandparent Sibling Cousin Other

Adult(s) Living with Participant Contact Details

Parent/Guardian (Secondary)

First Name 

Last Name

Daytime Phone

Cell Phone

Email

Relationship with Participant

Please select... Mother Father Aunt Uncle Grandparent Sibling Cousin Other

EMERGENCY CONTACT

First Name 

Last Name

Daytime Phone

Cell Phone

Email

Relationship with Participant

Please select... Mother Father Aunt Uncle Grandparent Sibling Cousin Other

INCOME ELIGIBILITY

Please attach recent Bank Statement, Payroll Stub, Tax Return or Self-Certify to apply for services under BYA's Discounted Fee Schedule.

Check all that apply

Single Parent FamilyDisabledChronically HomelessHomeless/Couch SurfingPrevious or Current Foster YouthPregnant or ParentingEmployed or in Job Training?

Family Receives Public Assistance?

Please select... YES NO

AFDC/TANF/Cal Works?

Please select... YES NO

Cal FRESH (Food Stamps)?

Please select... YES NO

Medi-Cal?

Please select... YES NO

Social Security Income (SSI)?

Please select... YES NO

Disability?

Please select... YES NO

Unemployment?

Please select... YES NO

Other, Self-Certify

HOUSEHOLD SIZE

Please select... 1 2 3 4 5 6

INCOME LEVEL

Please select... $11,770 $15,930 $20,090 $20,500 $23,400 $24,250 $26,350 $28,410 $29,250 $31,600 $32,570 $33,950 $34,150 $39,000 $43,900 $48,750 $52,650 $56,550 $60,150 $67,650 $75,150 $81,200 $87,200

How were you referred? 

Please select a choice below

Social MediaFlyerBYA WebsiteFamily/FriendOther

You selected 'other' please provide how you were referred below

*Extended Care Program Applicants Only*

Please email completed waivers to Audrey Cashen at acashen@byaonline.org

Please print or upload the applicable waiver and/or release form below

Upload Applicable Waiver/Release Form Here

Photo Release Form

Transportation Waiver

Extended Care Report Card Release Form