Date of Application: 2017/2018 Date Application Received:

Buckeye Hills Career Center

______Gallia-Jackson-Vinton Joint Vocational School District ______

P. O. Box 157, Rio Grande, Ohio 45674 – www.buckeyehills.net (BHCC Office Use Only)

APPLICATION FOR ADMISSION

This application must be returned to your high school counselor. All items must be completed. PLEASE PRINT.

To be accepted, applicants must have six (6) high school credits with four being in the core curriculum,

be at least 16 years of age during the first full week of October, and be in at least their third year of high school.

Applications are processed on a first come, first serve basis. Eligible students will be placed starting March 1, 2017.

Home High School (Circle One): GAHS JHS OHHS RVHS SGHS VCHS WHS Other______Present Grade:______

Name: (Last)______(First) ______(Middle) ______

Student Social Security #: ______/______/______Date of Birth:______/______/______Age:______Male □ Female □

Address: (Number)______(Street)______(City)______(Zip)______

Home Phone: ______If Applicable: (P.O. Box)______(City)______(Zip)______

Is the student of Hispanic/Latino origin? □ Yes □ No If no, please mark all that apply:

□ White □ American Indian or Native Alaskan □ Native Hawaiian or Pacific Islander □ Black or African American □ Asian

FATHER MOTHER

Name: ______Name: ______

Address: ______Address:______

______

Home Phone: ______Home Phone: ______

Cell Phone: ______Cell Phone: ______

Email: ______Email: ______

Place of Employment: ______Place of Employment: ______

Work Phone: ______Work Phone: ______

Name of Legal Guardian: ______Relationship: ______Phone: ______

Mailing Address: ______

(If different from above) Number Street City ZIP

CAREER OPPORTUNITIES THROUGH CAREER-TECHNICAL EDUCATION

Please indicate your first four choices by placing the numbers 1- 4 beside the appropriate programs.

ALLIED HEALTH ACADEMY HUMAN RESOURCE ACADEMY

_____ Diversified Health Occupations _____ Early Childhood Education

_____ Medical Office Assistant _____ Cosmetology

_____ Culinary Prep

BUSINESS AND MARKETING ACADEMY _____ Criminal Justice

_____ Computer & Electronic Engineering Technologies

CONSTRUCTION TRADES ACADEMY TRANSPORTATION ACADEMY

_____ Building & Grounds Maintenance _____ Agricultural & Diesel Mechanics

_____ Building Trades _____ Auto Collision Technology

_____ HVAC/Plumbing/Electrical _____ Auto Service Technology

_____ Welding

Reasons for my first career/technical program choice are:______

______


SPECIAL HEALTH CONCERNS:

a) _____None b)_____Allergies c) _____Asthma d) _____ Color Blind e)_____ Special Physical Considerations

(Handicapping conditions will not prohibit placement into an appropriate career/technical program.)

If any items other than (a) are checked above, please provide more information: ______
______

PARENT STATEMENT: I am interested in my son/daughter attending the Career Center because: ______

______

Please identify any factors that should be given special consideration in evaluating this student's application:

______

______

PLEASE NOTE: Students accepted into a career/technical program will be required to

attend classes at Buckeye Hills for two weeks. Any student wishing to return to their home high school

MUST have the paper work completed by the last day of the first two weeks of school.

Student Signature: ______Date: ______

Parent/Legal Guardian Signature: ______Date: ______

INFORMATION TO BE COMPLETED BY THE HOME HIGH SCHOOL COUNSELOR

EOC Exam Scores:

Test / Quality Points / Test / Quality Points / Test / Quality Points
Algebra 1 / English 1 / Biology
Geometry / English 2 / Physical Science
Integrated Math 1 / American History
Integrated Math 2 / Government

Number of credits completed prior to this school year: ______Number of credits anticipated for the current school year: ______

Birth Date (per official school record) Month______Day______Year______Date student entered 9th grade______

Please identify any factor that should be given special consideration in evaluating this student’s application______

Is this student Open-Enrolled from another district (what is the “District of Residence”)? ______

Signature of Home School Counselor ______Date______

PLEASE ATTACH AN OFFICIAL TRANSCRIPT

It is the policy of the Gallia-Jackson-Vinton Joint Vocational School District that educational programs and other activities be conducted in adherence to Title VI of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, and Section 504 of the Rehabilitation Act of 1973 in assuring non-discrimination with regard to race, color, national origin, sex and disability. A complaint may be filed with the U.S. Dept. of Education at any time, and it is not necessary for a person to go through the district’s grievance procedures before filing with the U.S. Dept. of Education. Complaints may be sent to U.S. Dept of Education, Team Leader, Office of Civil Rights, 600 Superior Ave. E, Suite 750 Bank One Center, Cleveland, Ohio 44104.