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Youth Initiative High School
Boarding Student Application for Admission
Student Health Information
*
Indicates required field
Student Name
*
First
Last
Insurance Information
Insurance Company Name and Address
*
Policy #
*
Will this policy cover student in Wisconsin?
*
No
Yes
Youth Initiative High School requires all students with Health Insurance to submit proof of insurance with relevant contact information to YIHS staff.
Local Emergency Contact Information ( if you do not have a host family ye
t
, leave this blank):
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Relationship to Applicant
*
Health Information:
Does your child take any medications on a regular basis? (please list)
*
Does your child have any allergies, including insect stings? Please list.
*
Has your child ever had seizures? If so, please explain.
*
Can your child be given any of the following in case of minor injury of headache? Please check all that apply.
*
Homeopathic remedy
Aspirin
Tylenol
Ibuprofen
We are required
by law to keep all stu
dent's vaccinati
on records on file.
Domestic Boarding Students:
Download, fill out, and return this required form before student arrives at YIHS
.
http://www.dhs.wisconsin.gov/forms/F0/F04020L.pdf
International Boarding Students:
After we receive your application, we will send you an immunization form. This form must be filled out and returned before student can attend YIHS.
I understand immunization records are required for my student to attend YIHS
*
Yes
No
I hereby give my consent for EMERGENCY MEDICAL CARE OR TREATMENT
Parent's Signature
*
Date
*
Submit and Continue to Student Tuition Agreement
Home
About
Welcome
Our Mission
Our School
Our Faculty
Our Story
School Community
Where We Live
FAQ
Curriculum
Academics
Beyond Academics
>
Expeditions
Senior Projects
Student Service
Sports
Initiative
>
Evaluations
Life After YIHS
>
College Acceptance
Admissions
How To Apply
Cost Of Education
>
Fundraising
Contact Us
Job Opportunities
Support Our Work
Donate
Community Partnership Program
News & Events
YIHS Comprehensive Calendar
Publications
Boarding Program