CORPUS CHRISTI ACADEMY Sacred Heart of Jesus Parish Saint Clare Parish Please print clearly in black or blue ink. Registration forms are to be submitted to Corpus Christi Academy Office. Parent Name___________________________ Student Last Name____________________________ Pre-Kindergarten Registration Agreement 2020-2021 School Year Registering as Parishioner: ( ) Sacred Heart of Jesus ( ) St. Clare ( ) Holy Rosary OR ( ) Non-Parishioner Registering as: ( ) Catholic ( ) Non-Catholic Registration is complete ONLY upon following: (1) Tuition payments are current for 2019-2020 with Corpus Christi Academy. (2) Payment of $100 per student must accompany this Agreement. Registration Fee is non-refundable. (3) Corpus Christi Academy and Parish Business Office review for accuracy and completeness. (4) Immunizations and Entrance Forms (required for all Pre-Kindergarten students) (5) Birth Certificate, Baptismal Certificate (if applicable) (new students) Father/Guardian Information Mother/Guardian Information ( ) Custodial ( ) Non-Custodial ( ) Custodial ( ) Non-Custodial Name __________________________________ Name ___________________________________ Address ________________________________ Address__________________________________ _________________________________ __________________________________ E-mail _________________________________ E-Mail___________________________________ Phone __________________________________ Phone___________________________________ (Please mark preferred phone) (Please mark preferred phone) Student Information Name (First & Last) Date of Birth Grade 2020-21 N (New) or R (Return) ____________________________ ________________ ________ _________ ____________________________ ________________ ________ _________ ____________________________ ________________ ________ _________ ____________________________ ________________ ________ _________
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CORPUS CHRISTI ACADEMY...Tuition Rates Program Enrolled Tuition Non Parishioner Parishioner Half Day $2,700.00 $2,600.00 Full Day $4,350.00 $4,150.00 SCHOLARSHIPS Corpus Christi Academy
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CORPUS CHRISTI ACADEMY
Sacred Heart of Jesus Parish Saint Clare Parish
Please print clearly in black or blue ink.
Registration forms are to be submitted to Corpus Christi Academy Office.
Parent Name___________________________
Student Last Name____________________________
Pre-Kindergarten Registration Agreement 2020-2021 School Year
Registering as Parishioner: ( ) Sacred Heart of Jesus ( ) St. Clare ( ) Holy Rosary
Total Family Tuition (prior to application of financial assistance): $4,250.00 Full Day
$2,600.00 Half Day
Fees:
• $100.00 non-refundable registration fee per student
Total Family Tuition and Fees: $4,350.00 Full Day
$2,700.00 Half Day
I agree to pay Corpus Christi Academy the tuition and all fees for the attendance of my child(ren) as established by the school for the 2020-2021 school year. I elect to pay the tuition and fees as follows. Please mark
preferred payment method(s):
Preferred
Payment
Option
Payment Type Payment
Amount
Payment Guidelines and Due Date
One Full Payment by cash
or check
Make checks payable to Corpus Christi Academy.
Payment due July 20, 2020. ($100.00 discount if tuition
Date:_________ Signature of Parent:___________________________________________
Transportation: (please check one) Bus_________ Walk________ Parent Pick-Up_________ If your child does not go directly home after school, please list where the child goes, on what days, with
phone numbers. Name_____________________________________________Phone Number_______________________ M T W TH F
*CONTINUE TO BACK OF THIS PAGE TO COMPLETE FORM*
Please provide your child’s medical-care provider information below: Doctor: Name:_________________________________________
PRIVACY ACT: It is understood that no student information will be given out without parental consent. However, we wish to inform you that your name and home phone number will be given
to selected adults who will keep the information confidential and will use it only to inform you of emergency situations. This procedure will replace our old method of informing parents of an
emergency school closing. If you have any problem with this policy, please call me in the school office at
(440) 449-4242. I have read the above statement regarding the Privacy of Student Information.
PART I (TO GRANT CONSENT) In the event reasonable attempts to contact me at: ( )__________________ or _______________________ (phone) (other parent) at ( )_____________________ have been unsuccessful, I hereby give my consent for:(1) the administration of any treatment deemed necessary by Dr._____________________, or Dr.______________________ or in the (dentist) (physician) event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to:____________________________________ hospital or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity for such surgery, are obtained before surgery is performed.
Date:_______ Signature of Parent or Guardian:___________________________________
PART II (REFUSAL TO CONSENT)
DO NOT COMPLETE PART II IF YOU COMPLETED PART I
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action
Does the non-residential parent have visitation rights?_____YES _____NO
Is there a court decision that states that the non-residential parent should NOT receive school
information or attend school activities?
_____YES _____NO
Is the non-residential parent responsible for paying tuition? _____YES _____NO
PreSchool Entrance Medical Record & Physical Form Child’s Name Date of birth
___This above named child has been examined, the immunization status recorded, and the child is in suitable condition for participation in group care. ___This above named child has been immunized in accordance with the requirements of section 5104.014 of the Ohio Revised Code (please note any exceptions below Signature of examining Physician/Physician’s Assistant/Advanced Practice Registered Nurse/Certified Nurse Practitioner
Date of Examination
Name of Physician/Physician’s Assistant/Advanced Practice Registered Nurse/Certified Nurse Practitioner
Telephone Number
Street Address City, State and Zip Code
ATTACH A COPY OF THE CHILD’S IMMUNIZATION RECORD WITH DATES OF DOSES OF
ALL IMMUNIZATIONS
Exceptions to immunization requirements pursuant to 5104.014 ORC (please include names of requirements diseases against which the child has not been immunized and whether it is because the immunization is medically contraindicated, not medically appropriate for the child’s age, or declined by the parent). ____I have declined to have my child immunized against one or more of the diseases required by 5104.014 of the Ohio Revised Code. Please note above and sign Signature of Parent