Grace Academy Elementary/Middle Application Packetgraceacademyrockwell.com/clientimages/48671/elementary...6725 HWY 152 E APPLICATION PACKET ROCKWELL, NC 28138 704.279.6683 2010-2011

GRACE ACADEMY KINDERGARTEN – SIXTH GRADE

6725 HWY 152 E APPLICATION PACKET

ROCKWELL, NC 28138

704.279.6683

www.graceacademyrockwell.com 2010-2011

Pag

e1A

Grace Academy Elementary/Middle Application Packet

Table of Contents…………………………….…………………………………………Page 1A

Student Application Form: (Choice of Programs) ……………………………………....Page 2A

Student Information, Parent Information, Pick-up Authorization...……………………..Page 3A

Travel and Activity Authorization .……………………………………………………...Page 4A

Medical/Emergency Information ….…………………………………………………….Page 4A

Consent and Release Form ………………………………………………………………Page 5A

Parent Commitment …..………………………………………………………………….Page 6A

Parent Financial Agreement ..……………………………………………………………Page 7A

G.A. Discipline and Behavior Management Policy .……………………………………..Page 8A

Parent Signature Required: Discipline Policy …………………………………………...Page 9A

Photo Release Form ..…………………………………………………………………….Page 9A

Student Medical Report ………………………………………………………………….Page 10A

Physical…………………………………………………………………………………...Page 11A

Immunization Record ……………………………………………………………………Page 12A



ROCKWELL, NC 28138

704.279.6683


Pag

e2A

APPLICATION for Admission

NOTE: To apply for enrollment follow the steps listed below. Check the box above for program applying for.

Fill out application forms and turn in with all fees that apply. (PHYSICAL & SHOT RECORDS ARE DUE BY

AUGUST 1, 2010. RETURNING STUDENTS DO NOT NEED AN UPDATED PHYSICAL OR A IMMUNIZATION

COPY UNLESS CHANGES HAVE BEEN MADE OR ANY NEW MEDICAL CONDITION.)

____ New Student ____ Returning Student

Student Name______________________________________________________ Goes by:_____________

First Middle Last

Gender (circle) M F Date of Birth__________________ Age______ Grade applying for_______

T- Shirt Size: (parent please choose) ___ Child’s Small (6-8) ___ Child’s Medium (10-12)

___Child’s Large (14-16) ___ Adult’s Small ___ Adult’s Medium ____Adult’s Large

Office Use Only: (check when received)

_____Student/Parent Information

_____Medical Information

_____Travel & Activity Authorization

_____Consent and Release Form

_____Parent Commitment _____Parent Financial Agreement

_____Discipline/Behavior Policy

_____Photo Release

_____Student Medical

_____Immunization Record

Office Use Only

Date of Enrollment: _____________________ Sec. Int._____

App. Fee: Ck #____________ $_____________

Book Fee: Ck #____________Date___________ $___________

Craft Fee: Ck #____________ Date___________ $___________

Tuition Paid (Date):______________ $______________

Grade: __________ Teacher:_____________________

Tuition: $275.00 - _____ Sibling discount - _____ Multi-program

discount + ________ BS / AS =____________ per month

Elementary or Middle

School

NEW Application Fee:

K5- 6th grade

$50.00 ______

Re-enroll after 3-1-10

$65.00______

Combo 1: Elem. /Middle

& Before School


*Both fees apply

K5- 6th grade

$50.00 ______

Before School Care

$50.00 ______


$65.00______ each

*Request separate handbook

Tuition: $275.00 per month

BS Care $65.00 per month

-$10.00 discount

= $330.00 per month

Combo 2: Elem./Middle

& After School


*Both fees apply

K5- 6th grade

$50.00 ______

After School Care

$50.00 ______


$65.00______ each

*Request separate handbook


AS Care $130.00 per

month

-$20.00 discount

= $385.00 per month

Combo 3: Elem./Middle,

Before & After School


*Both fees apply

K5- 6th grade

$50.00 ______

Before & After School

Care combo App. Fee:

$50.00 ______


$65.00______ each


B & AS Care $180.00 per

month

-$20.00 discount

= $435.00 per month

All Day Camp (only)


K5- 6th grade

$50.00 ______


$65.00______

Tuition: $25.00 per day



ROCKWELL, NC 28138

704.279.6683


Pag

e3A

Student Information Date of Enrollment: (child’s first day of school) ____________________________

Name: ______________________________________________________________________________________________ DOB _________________________

(First) (Middle) (Last)

Address: __________________________________________________________________ City________________________ State _______ Zip______________

Mailing Address (if different):___________________________________________________________________________________________________________

Gender: ___ Male ___ Female Nationality: _____________________

Previous School Attended: ________________________________________________________________________________________________________

Name City, State Phone

Year attended:____________________ Grade:________ Reason for transfer/withdrawal: ________________________________________________________

Parent Information _____ Father responsible for billing _____ Mother responsible for billing

Father/Guardian Name: ___________________________________________ __ Mother/Guardian Name: _________________________________________

Address: _________________________________________________________ Address _______________________________________________________

Home Phone: _____________________________________________________ Home Phone: __________________________________________________

Employer: ________________________________________________________ Employer: _____________________________________________________

Business Phone: _________________________________________________ __ Business Phone: ________________________________________________

E-mail: __________________________________________________________ E-mail: _______________________________________________________

Cell Phone: _____________________________________________________ __ Cell Phone: ____________________________________________________

Parents are: _____ Married _____ Separated _____ Divorced _____ Single _____ Remarried Parent Deceased? _____ Father _____ Mother

If the parents are divorced, who has legal custody? _______________________________________________ Can both parents pick up the student? ____________

Other Children in Family:

________________________________________________________________ _____________________________________________________________

Name School Grade Age Name School Grade Age

________________________________________________________________ _____________________________________________________________

Name School Grade Age Name School Grade Age

Pick-Up Authorization

Persons other than parents authorized to pick up child; if parents cannot be reached.

Name_____________________________________________________ Phone #_____________________________________Relationship_____________________




Parent signature(s) ______________________________________________________________________________________Date____________________________

The people listed below DO NOT have my permission to pick my child up from Grace Academy.

Name_______________________________________________________ Phone #________________________________Relationship________________________

Name_______________________________________________________ Phone #________________________________Relationship________________________



ROCKWELL, NC 28138

704.279.6683


Pag

e4A

Travel and Activity Authorization

This is a blanket permission for all given activities for Grace Academy within the 2010-2011 school year unless noted

below.

_______________________________________________________________________________________________

I, _________________________________ parent/guardian of ____________________________ give my perrmission Parent/guardian Student’s Name

to ___Grace Academy ____ __ for my child to participate in the following activities:

Scheduled field trips by bus and away from the facility as well as educational trips to the library during the 2010-2011

school year.

_______________________________________________________________________________________________

Explain planned activity—where and when

I understand that the facility will use the appropriate child restraint devises (if required by law) and abide by all the

safety rules in Rule.1000 NCCCD when my child is transported in a vehicle. The facility will also notify me each time

that my child is to participate in an activity that would involve transportation.

Parent/Guardian Signature__________________________________________________ Date ___________________

This authorization is valid from August 25, 2010 to June 10, 2011 .

IN CASE OF AN EMERGENCY

You may contact the persons listed below in the event a parent cannot be reached.

Name_______________________________________ Relation to child_____________________________

Phone Number_______________________________ Alternate phone#____________________________

Name_______________________________________ Relation to child_____________________________

Phone Number_______________________________ Alternate phone#____________________________

Parent Signature_________________________________________ Date__________________



ROCKWELL, NC 28138

704.279.6683


Pag

e5A

CONSENT AND RELEASE FORM

I, the undersigned parent or guardian, hereby consent to my child, ____________________________, participating in

activities as assigned with Grace Academy, and/or sponsored by Grace Bible Church during the 2010-2011 school

year. I certify that my child is able to participate in activities, which may include: indoor games, use of playground

equipment or travel as a passenger in vehicles used for transportation arranged by Grace Academy Staff. If my child

has medical conditions, which may be relevant to a physician in the event of an emergency, I have listed them below.

In the event that an emergency may occur, I may be reached at the telephone number listed below. If I cannot be

reached, I hereby authorize __Grace Academy __ to make emergency medical decisions for my child. If there

are any activities I do not want my child to be involved in, I have listed them below.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE

ENCOUNTERED ON SAID ACTIVITY, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT

THERETO. I do hereby agree to hold Grace Bible Church staff, Grace Academy staff and counselors, harmless from

any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or

property, even injury resulting in death, which I now have or which may arise in the future in connection with the

activity or participation in any other associated activities.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted

by the law of the State of North Carolina and that if any portion thereof is held invalid, it is agreed that the balance

shall, not withstanding, continue in full legal force and effect. This release contains the entire agreement between the

parties hereto and the terms of this release are contractual and not a mere recital.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE

CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding

agreement which I have read and understand.

MEDICAL CONDITIONS TO BE AWARE OF:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

TELEPHONE NUMBER WHERE I MAY BE REACHED IN AN EMERGENCY:

_______________________________________________________________________________________________

GUIDELINES SLIP

I have read, understand and agree with the guidelines within Grace Academy Elementary and Middle School

Handbook. I have also discussed the guidelines with my child and we/I am in agreement with the set policies.

Mother/ Guardian Signature_______________________________________________________________Date______________________

Father/ Guardian Signature _______________________________________________________________ Date______________________



ROCKWELL, NC 28138

704.279.6683


Pag

e6A

Parent Commitment

As the parents/guardian, we agree to the statements listed below:

Upon registering/enrolling my child at Grace Academy, I agree to abide by the policies outlined in the student handbook and other policies that might be instated as the year progresses. I agree to abide by all financial policies, all forms of discipline, methods of study, courses of study, and any rules and regulations so stated or implied. All fees are non- refundable and non-transferable. I agree to give a 2 week notice if I should withdraw my child from Grace Academy. I understand the parent or guardian is responsible for the 2 week tuition period even if the child is not in attendance. I agree to abide by the judgment and decisions of the administration concerning my child.

We understand that Grace Academy will teach that the Bible is the inspired word of God, that it is without error, and that it is

our guide for all areas of human living.

We understand that Grace Academy will cooperate with the home by reporting the progress of the children and by holding

conferences with parents. We agree to support the school by our participation in the conferences and programs which pertain to

our child.

We understand that children will be encouraged to perform to the best of their ability in academic work, as well as in all other

endeavors. We will therefore provide the support and cooperation necessary to create an enhanced learning environment.

We understand our need to set a good example for our children by being prompt, by supporting school policies, and by

supporting the classroom teacher. We will attempt to set a positive tone in developing attitudes regarding school. We will

therefore refrain from making negative comments to our children or to other parents; we will take our concerns to the teacher

first and then to the administration if necessary. If our dissatisfaction is still unresolved, we will quietly remove our child from the

school.

We understand that a child may be dismissed if he/she becomes a disruptive influence in the spiritual life or educational process

of the school or if he/she does not respond positively to the programs of the school.

We understand our cooperation is expected in prompt tuition payment, occasional special fees (field trips), practical help and

faithful prayer. We understand that failure to make payments as necessary may result in the dismissal of our child from the

school.

I /we have read and agree to support the Parent Commitment of GA Elementary and Middle School.

Student Name ______________________________________________ Grade ______________________

Mother/ Guardian Signature ___________________________________ Date _______________________

Father/ Guardian Signature ____________________________________ Date _______________________



ROCKWELL, NC 28138

704.279.6683


Pag

e7A

Parent Financial Agreement

Upon enrolling my child at Grace Academy, I agree to abide by the policies outlined in the student

handbook and other policies that might be instated as the year progresses.

I agree to abide by all financial policies, all forms of discipline, methods of study, courses of study,

and any rules and regulations so stated or implied.

I agree to pay tuition and fees when due. Tuition is due by the 1st of the month. Any tuition received

after the 10th

of a month is subject to a $25 late fee.

Unpaid balances cannot be carried over from one month to the next. If your account becomes two

months past due, your child may be subject for dismissal.

Tuition is non-refundable if the student has been to school any day during the month, or if a 2 week

written notice of withdrawal has not been submitted to the director. Exception will be made if the

account has been paid in full for the school year.

A 2 week notice is required if your child is to be withdrawn from our center. The parent or guardian

is responsible for the 2 week tuition period even if the child is not in attendance.

All fees are non- refundable and non-transferable.

I agree to abide by the judgment and decisions of the administration concerning my child.

There will be a $35.00 NSF fee on all returned checks, regardless of the reason for the return. After

two returned checks, account will be on a cash only basis. All NSF checks and fees should be taken

care of within one week of being returned or your child will be subject to dismissal.

I /we have read and agree to abide by the Parent Financial Agreement of Grace Academy

Student Name ____________________________________________________ Grade _________________

Mother/ Guardian Signature _________________________________________ Date__________________

Father/ Guardian Signature __________________________________________ Date__________________



ROCKWELL, NC 28138

704.279.6683


Pag

e8A

G.A. Elementary and Middle School Discipline and Behavior Management Policy

Discipline: It would be impossible to make rules to govern every type of infraction. Good behavior must come from the

heart in love and obedience to Jesus Christ and should not be merely conformity to man-made regulations. Proper

attitude is a measure of a person’s spiritual life. Listed below are some general items of conduct. a. Respect for authority at all times. b. Use of proper speech: Adults should not be answered with “yeah” or disrespectfully. Any type of vulgarity,

boisterous action and talk will not be tolerated. Col.3:8 – “But now ye also put off all these: anger, wrath, malice, blasphemy, filthy communication out of your mouth.”

c. Destruction of property that belongs to the school, church, fellow students or staff will not be tolerated. d. Modest dress should be maintained at all times. e. Chewing gum is not permitted on school grounds, in buildings or buses. f. Any student caught cheating will automatically receive a zero for that assignment or test. g. Any other rules considered necessary by the school will be enforced.

We strive to be FIRM, FAIR, CONSISTANT, and LOVING. Corporal punishment is not administered at Grace Academy. The teacher/director will inform the parent of serious or consistent

behavioral problems and seek parental suggestions before taking further actions.

General Rules:

We expect all our students to demonstrate the following general attitudes and behavior:

1. Respect and obedience to authority at all times.

2. Reverence for the Word of God, the American flag, and the Christian flag.

3. Proper care of all school, student, church and staff property.

4. Proper and modest attire, speech, and actions. Col. 3:8- “ But now ye also put off all these: anger, wrath, malice,

blasphemy, filthy communication out of your mouth.”

5. Orderly, courteous conduct in and out of the classroom and on the playground.

6. Show respect to classmates.

7. Chewing gum is not permitted on school grounds, in buildings or buses.

8. Any student caught cheating will automatically receive a zero for that assignment or test.

9. Any other rules considered necessary by the school will be enforced

Playground and outdoor rules:

1. Students should walk to and from the playground in single file.

2. Swings and slides should be used by one person at a time. Students should be seated when swinging or sliding.

3. Students are to go down the slides facing forward only.

4. Slide on bottoms only. After sliding, clear the space so others may slide.

5. NO swinging on the cross bars and NO jumping from the equipment. NO horse play.

6. Only one person should climb the slide ladder at a time.

7. NO playing with or throwing bark or rocks. Sand should stay in the sandbox.

8. No climbing on the fence.

9. Use the picnic tables for sitting or eating.

10. Be gentle and courteous when touching others.

11. Do not imitate violent role models, i.e. Power Rangers, X-Men, etc…

PLEASE GO OVER THESE POLICIES WITH YOUR CHILD. KEEP THIS PAGE FOR YOUR RECORDS, SIGN AND

RETURN THE FOLLOWING PAGE.



ROCKWELL, NC 28138

704.279.6683


Pag

e9A

I, the undersigned parent/guardian of_____________________________________, do hereby state that I have read and agree with

the Grace Academy’s Discipline and Behavior Management Policy.

Mother/Guardian Signature __________________________________________________________ Date____________________

Father/Guardian Signature ___________________________________________________________ Date____________________

Photo Release Form

Student Name: ___________________________________________________________________Grade: ___________________

I give Grace Academy permission for the following areas.

Grace Academy has permission to photograph or videotape my child for school related activities and functions.

Grace Academy has rights to publish pictures or videos on the School Web-Site, School Brochures, or Newspaper Articles.

I/we have read, understand and agree to the above policy of Grace Academy. I/we also understand that this consent form will

remain on file for the academic school year, beginning August 25, 2010 through June 10, 2011.

Mother/Guardian Signature __________________________________________________________ Date____________________

Father/Guardian Signature ___________________________________________________________ Date____________________

*********************************************************************************************************

How did you hear about our program?__________________________________________________



ROCKWELL, NC 28138

704.279.6683


Pag

e2A

Student Medical Report (to be completed by Parent and returned to school office)

Student’s Name __________________________________________________________ DOB ____________________________

Address__________________________________________________ City_____________________ State ____ Zip __________

Parent or Guardian_______________________________________________________ Phone ____________________________

Family Physician _____________________________________City _________________________Phone __________________

Family Dentist _______________________________________City _________________________Phone __________________

Insurance Carrier____________________________________________ Policy # _______________________________________

Hospital Preference _______________________________________________ Phone # __________________________________

Medical History (to be completed by Parent)

1. Allergies No Yes Please list: _____________________________________________________________________

2. Asthma No Yes List medication: _________________________________________________________________

3. Diabetes No Yes List medication: _________________________________________________________________

5. Is the child on any continuous medication? (Insulin, Dilantin, Ritalin, etc.) No Yes If yes, please list?

_________________________________________________________________________________________________________

5. Does the child have any physical or mental disabilities: No Yes If yes, please describe:

_________________________________________________________________________________________________________

6. Any Previous Hospitalizations or Operations? No Yes If yes, when and for what?

_________________________________________________________________________________________________________

I agree that the operator of Grace Academy may authorize the physician of his/her choice to provide emergency care in the event

that neither I nor the family physician can be contacted immediately.

Mother/ Guardian Signature ______________________________________________________ Date_______________________

Father/ Guardian Signature _______________________________________________________ Date_______________________

I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of an emergency. In an

emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any

medication without specific instructions from the physician or the child’s parent, guardian, or full time custodian. Provisions will

be made for adequate and appropriate rest and outdoor play.

Signature of Director ___________________________________________________________ Date _______________________



ROCKWELL, NC 28138

704.279.6683


Pag

e3A

NOTE: RETURNING STUDENTS (1ST – 6TH ) DO NOT NEED AN UPDATED PHYSICAL OR AN UPDATED

IMMUNIZATION COPY UNLESS CHANGES HAVE BEEN MADE OR ANY NEW MEDICAL CONDITION.)

Physical Examination:

To be completed and signed by a licensed physician, his authorized agent currently approved by the N.C. Board of Medical Examiners (or a

comparable board from boarding states), a certified nurse practitioner, or public health nurse meeting DEHNR standards for EPSDT program.

Child’s name_____________________________________ DOB _____________________

Height (inches) __________ Weight (lbs) __________

Head __________ Eyes __________Ears __________ Nose __________ Teeth __________

Throat __________ Neck __________ Heart __________ Chest __________ Abd/GU __________

General Appearance: Good __________ Fair __________ Poor __________

Ext __________ Neurological System _______________ Skin __________

Results of Tuberculin Test, if given: Type __________ Date __________ Normal ______ Abnormal ______

Should activities be limited? No Yes If yes, explain:

_________________________________________________________________________________________________________

Does the child have any physical or mental disabilities: No Yes If yes, please describe:

_________________________________________________________________________________________________________

________________________________________________________________________________________________________

Any other recommendations: _________________________________________________________________________________

_________________________________________________________________________________________________________

Date of Examination: ______________________

Signature of Authorized Examiner/Title: ____________________________________________

Phone # __________________________



ROCKWELL, NC 28138

704.279.6683


Pag

e4A

Immunization Record

Student’s Name ____________________________________________

Gender: ____M ____F DOB: _________________

Enter the date an immunization was received in the space below or attach a copy of the immunization record. G.S. 130A-155(b)

requires all childcare facilities to have this information on file.

Enter date of each dose – Month/Day/Year

Required Immunizations

#1 Date

#2 Date

#3 Date

#4 Date

#5 Date

DTP or DT Diphtheria, Tetanus,

Pertussis

Polio

MMR Measles, Mumps,

Rubella

(combined doses)

Hep B

Hepatitis B

Hib

Haemophilus

influenza type B

Varicella

Chickenpox

Other

Other

*Required by State Law

**Required by State Law for children born on or after 10/1/88

***Required by State Law for children born on or after 7/1/94

****Required by State Law for children born on or after 4/1/01

Grace Academy Elementary/Middle Application Packetgraceacademyrockwell.com/clientimages/48671/elementary...6725 HWY 152 E APPLICATION PACKET ROCKWELL, NC 28138 704.279.6683 2010-2011

Documents