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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
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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
NEW Application Fee:
*Both fees apply
K5- 6th grade
$50.00 ______
Before School Care
$50.00 ______
Re-enroll after 3-1-10
$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
NEW Application Fee:
*Both fees apply
K5- 6th grade
$50.00 ______
After School Care
$50.00 ______
Re-enroll after 3-1-10
$65.00______ each
*Request separate handbook
Tuition: $275.00 per month
AS Care $130.00 per
month
-$20.00 discount
= $385.00 per month
Combo 3: Elem./Middle,
Before & After School
NEW Application Fee:
*Both fees apply
K5- 6th grade
$50.00 ______
Before & After School
Care combo App. Fee:
$50.00 ______
Re-enroll after 3-1-10
$65.00______ each
Tuition: $275.00 per month
B & AS Care $180.00 per
month
-$20.00 discount
= $435.00 per month
All Day Camp (only)
NEW Application Fee:
K5- 6th grade
$50.00 ______
Re-enroll after 3-1-10
$65.00______
Tuition: $25.00 per day
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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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_____________________
Name_____________________________________________________ Phone #_____________________________________Relationship_____________________
Name_____________________________________________________ Phone #_____________________________________Relationship_____________________
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________________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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__________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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______________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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 _______________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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__________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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.
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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?__________________________________________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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 _______________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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 # __________________________
GRACE ACADEMY KINDERGARTEN – SIXTH GRADE
6725 HWY 152 E APPLICATION PACKET
ROCKWELL, NC 28138
704.279.6683
www.graceacademyrockwell.com 2010-2011
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