Student Name: Parents/Guardians Name: 2017-2018 … · Student Name: Parents/Guardians Name: 2017-2018 ... The following individuals are authorized to pick my child up from ... Jesus

Maryville Christian School 7110 State Route 162 P.O. Box 579 Maryville, Illinois 62062 ph 618-505-7000, ext. 500 fax 618-505-7005 website: maryvillechristian.org

________________________________________ ________________________________________ Student Name: Parents/Guardians Name:

2017-2018

Student Application for Admission Packet

Thank you for your interest in Maryville Christian School / Maryville Christian High School! Please review the enclosed

information and prayerfully consider enrolling your child(ren) in MCS / MCHS.

Completing this Student Application for Admission Packet is the first step in the process of enrollment. Once completed, submit

the application, along with a $250.00 registration fee, and all required forms and attachments to the school office for

consideration. Please be aware that applications will not be accepted without all completed forms and attachments,

including your child’s birth certificate. If you have questions, please contact us at 618-505-7000, ext. 500.

The following is enclosed in this packet:

-Student Application Checklist (for applicant use and reference)

-Student Application for Admission

-Parent/Guardian Statement of Doctrinal Beliefs

-Parent/Guardian Statement of Support

-ISBE Race and Ethnicity Data Form

-Kindergarten Questionnaire Release (for incoming Kindergarten students ONLY)

-Consent for Release of Student Records (for grades 1-11)

FOR OFFICE USE ONLY

Step One / Application Submission

Application completed & submitted / (date) ___________________ Both parents/guardians signed the Statement of Doctrinal Beliefs

$250.00 fee submitted Both parents/guardians signed the Parent/Guardian Statement of Support

Signed ISBE Race and Ethnicity Form

cash Signed Kindergarten Questionnaire Release (if applicable)

check #____________ date ____________ Signed Consent for Release of Student Records (if applicable)

credit card (all credit card transactions require an Copy of most recent report card submitted (if applicable)

additional fee of 5.5% to be added now) Copy of child’s birth certificate submitted

Kindergarten Questionnaire Release required / signed sent to school – date: ______________ received – date: _________________

Consent for Release of Student Records required / signed faxed to school – date: _____________ received – date: _________________

Step Two / Student Screening

Screening Required / (Kindergarten (or) 1st – 11th grade _________) / (date scheduled): __________________________ (time): __________________ (circle one)

Step Three / Parent Conference

Parent Conference scheduled / (date): ______________________ (time): __________________

Step Four / Status Notification

Review and prayerful consideration of applicant and family

Accepted Denied If denied - reason: _______________________________________________

Status letter sent (date): _________________________

Maryville Christian School 7110 State Route 162 P.O. Box 579 Maryville, Illinois 62062 ph 618-505-7000, ext. 500 fax 618-505-7005 website: maryvillechristian.org

Student Application Checklist

FOR PARENT USE ONLY – DO NOT RETURN – FOR YOUR REFERENCE ONLY

We are excited about your interest in Maryville Christian School / Maryville Christian High School. The following checklist will

assist you in completing the application process. If you have questions, please contact the school office at 618-505-7000, ext. 500.

Step One – Application Submission / ALL ATTACHMENTS MUST ACCOMPANY APPLICATION

Have you reviewed and completed the Student Application for Admission?

Have you enclosed the non-refundable application processing fee of $250.00?

Have both parents/guardians reviewed and signed the Statement of Doctrinal Beliefs?

Have both parents/guardians reviewed and signed the Parent/Guardian Statement of Support?

Have you completed the ISBE Race and Ethnicity Data Form?

Have you included a copy of your child’s birth certificate? BIRTH CERT. MUST BE INCLUDED FOR ALL STUDENTS

Have you completed and signed the Kindergarten Questionnaire Release? (if applicable)

Have you signed the Consent for Release of Student Records? (if applicable)

Have you included a copy of your child’s most recent report card? (if applicable)

Step Two – Student Screening

All prospective students are screened for admission. This process is necessary to gauge the academic, social, and emotional

readiness of incoming Kindergarten students. It also serves as a helpful tool to determine academic levels of older students in

order to meet their needs.

We/I have scheduled the student screening for: _____________________________________

Step Three – Parent Conference

The purpose of the parent conference is to explain the mission and expectations of the school and to allow parents the opportunity

to share their expectations of Maryville Christian School / Maryville Christian High School.

We/I have scheduled the parent conference for: _____________________________________

Step Four – Status Notification

A complete review of the application and prayer regarding each family will be used to determine acceptance to Maryville

Christian School / Maryville Christian High School.

A letter detailing your admission status will be mailed to you within two - four weeks of your interview.

We/I have received a letter detailing our/my child(ren)’s admissions status.

Step Five – Prepare for School

We/I will pay outstanding fees and tuition as outlined in the Fees and Tuition Schedule.

We/I will complete all necessary health and medical requirements (available at maryvillechristian.org or in the school

office) for my child and bring completed forms to Registration.

Date of Application: _______________________

Student's Full Namename child goes by

age birthdate gender

( ) male ( ) female

student's race

Student's Addressstate

state

(circle all that apply

for each email)

home / work

home / work

If separated or divorced:does non-custodial parent have visitation privileges? _______________to whom should notices of school activities and school correspondence be sent? ________________________________

Tuition Assistance may be available to qualified applicants. Please contact the school office for information.

How did you hear about MCS/MCHS? ________________________ Religious Affiliation _____________________ Home Church ___________________________________

Names and Ages of Siblings _____________________________________________________________________________________________________________

employer and occupation

Most non-confidential communications will be sent via email. Please list ONLY those email addresses that you wish to

receive school communications. At least ONE email address MUST be listed.

cell phone work phone

work phone cell phone

zipstreet address city


last name


home phonerelationship to student

SECONDARY Family Information (not listed above)

legally entitled to be contacted and receive report cards, progress reports, and mailingslast name first name

STUDENT INFORMATION

PRIMARY Family Information (with whom student resides)

last name first name middle

grade entering

zip

student's home phone

street city

ethnicity

( ) Hispanic ( ) not Hispanic

Motherfirst name

work phone

first name

cell phone

last name

Maryville Christian School / Maryville Christian High School does not discriminate against students of any race, color, national and ethnic origin, or social status for admission or in the

administration of its educational policies, or other school administrated programs. MCS / MCHS is a ministry of First Baptist Church of Maryville and is founded on principles of the Christian

faith. Parents and students are expected to read, support and agree with the statement of beliefs attached herein and the MCS / MCHS Parent-Student Handbook. Substantial

disagreement/infractions with school policies or philosophy is sufficient for dismissal of a student after enrollment.

Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Separated ( ) Widowed

Maryville Christian School /

Maryville Christian High School

2017 - 2018

Student Application for

Admission

Relationship to student: ________ (Enter the number describing the relationship of the primary guardian to the student)

EMAIL INFORMATION

Primary parent/guardian emails: Secondary parent/guardian emails:

mom / dad

home / work mom / dad



home / work

(circle all that apply for

each email)

1-both parents; 2-mother guardian; 3-father guardian; 4-mother/stepfather; 5-father/stepmother; 6-both guardians; 7-foster parents; 8-other

Father

Maryville Christian School P.O. Box 579 Maryville, Illinois 62062 Ph 618-505-7000 fax 618-505-7005

Student: _________________________________

School Last Attended by Student

State Zip

Has student ever been: Expelled ( ) Suspended ( ) Referred to Administration for Disciplinary Reasons ( )

If so, please give details and/or attach a copy of the evaluation:

Has student ever had an I.E.P. (Individual Education Program)? Yes ( ) No ( )

If so, please give details and attach a copy of student's I.E.P. and all evaluations:

2017 - 2018


Admission


Maryville Christian High School

Address City

Dates Attended Grades Attended Grades Skipped or Repeated (if any) Reason for Skipped or Repeated Grade

EDUCATIONAL BACKGROUND INFORMATION

Please include Preschool Information (if applicable)

Name of School Phone Number Fax Number


Student: _________________________________

Phone Number

Dosage

Mental Health Concerns

Policy Number Group Number Phone Number

Parent/Guardian Signature Date

Parent/Guardian Signature Date

2017 - 2018


Admission

Name Relationship to Child Phone Number

The following individuals are authorized to pick my child up from school. I understand that , in the event that I arrange for someone, other than the

persons listed, to pick my child up from school, I will be required to notify the school office in writing, by email, or by telephone before my child can be

released. I further understand that the MCS staff may ask that identification be provided, by the person picking my child up, prior to releasing my child.



MEDICAL INFORMATION AND EMERGENCY TREATMENT AUTHORIZATION (con't.)

AUTHORIZATION/RELEASE FOR EMERGENCY TREATMENT - HOLD HARMLESS AGREEMENT



MCS will follow the recommended medical procedures as outlined by the Illinois State Board of Education and the Illinois Department of Human

Services. First Aid will be administered by the school nurse. Serious injuries will receive first aid via emergency services.

In the case of injury or serious illness, Maryville Christian School will make every reasonable effort to contact the child's parent/legal guardian. As the

child's parent/legal guardian, if I cannot be reached, I give permission for Maryville Christian School staff to do whatever is needed to provide care and

treatment for my child. I further give Maryville Christian School staff permission to call an emergency paramedic ambulance service or transport my child

to the nearest emergency room.By signing below, I verify that all information provided in this application is true and correct and I agree to protect, indemnify, save and keep harmless,

Maryville Christian School & all of its staff, personnel and representatives, Kid's Club Program & all of its staff and personnel, and First Baptist Church of

Maryville & all of its staff, personnel, and representatives against and from any and all loss, cost, damage or expense, arising out of or from any accident

occurring while my child is participating in a school sponsored event. I understand that normal provisions will be made to supervise my child on and off

campus.

PICK-UP AUTHORIZATION

Allergies Vision or Hearing Difficulties Other Health Conditions/Concerns

INSURANCE INFORMATION

Medical Insurance Company Name of Insured

Primary Care Doctor Phone Number Dentist

Preferred Hospital Current Medication Reason for Medication

MEDICAL INFORMATION


Maryville Christian High

School

(EMERGENCY) CONTACT INFORMATION / other than parentsFirst Alternate Contact Information

Name / Relationship Daytime Phone Number Cell Phone Number

Second Alternate Contact Information Name / Relationship Daytime Phone Number Cell Phone Number

MEDICAL INFORMATION AND EMERGENCY TREATMENT AUTHORIZATION


STATEMENT OF DOCTRINAL BELIEFS

As stated on the Parents’ / Guardians’ Statement of Support, the parents and /or guardians acknowledge receipt of these doctrinal beliefs. Each

faculty member also signs a statement affirming his or her adherence to these doctrinal positions.

God the Father: God as Father reigns with providential care over His universe. He is all powerful, all loving, and all wise. (Gen. 1:1, Gen. 1:26-27,

Gen. 2:7, Gen. 3:22, and Psalms 90:2).

God the Son: Jesus Christ is the eternal Son of God. Jesus perfectly revealed and did the will of God, taking upon himself the demands and

necessities of human nature and identifying himself completely with mankind, yet without sin. He offered himself as the perfect sacrifice for the sins

of all humanity by dying on the cross. He arose from the dead after three days to demonstrate God’s power over sin and death. He ascended into

heaven and is now exalted at the right hand of God. He is the only mediator and reconciler between God and man. He will return in power and glory

to judge the world and rule as King of kings. (Matt. 1:22-23, John 1:1-5, Phil. 2:5-11, Col. 1:13-22, Col. 2-9, and Thess. 4:14-18).

God the Holy Spirit: The Holy Spirit enables men to understand the truth of the Gospel. He exalts Christ. He convicts of sin, righteousness, and of

judgment. He calls men to the Savior and seals the believer until the day of redemption. He is present in the life of every believer enlightening them

and empowering them to be used by and to know the eternal God. (John 16:7-13, Acts 1:8, Eph. 1:13, and Eph. 5:18).

The Bible: The Holy Bible was written by men divinely inspired by God. It has God for its author, salvation for its end, and truth, without any mixture

of error, for its matter. It is the inerrant, infallible Word of God and the supreme standard by which all human conduct, creeds, and religious

opinions should be tried. (2 Tim. 3:16, 2 Peter 1:20, and Psalms 119:105).

Mankind: Man was created by God in His image and is the crowning work of creation. In the beginning, man was without sin and endowed by His

Creator with freedom of choice. Man chose to rebel against God and brought sin into the human race; whereby all humanity has inherited a sin

nature and an inclination toward sin. (Gen. 1:27 and Romans 3:23).

Salvation: Salvation is God’s free gift to each of us. It cannot be earned. It must be received through the repentance of sins, faith in Christ, and the

receiving of Jesus as one’s eternal Master. (Rom. 6:23, Eph. 2:89, Rom. 10:9-10, and Rom. 10:13).

Eternity: God created mankind for the purpose of living and fellowshipping with Him forever. All who have experienced forgiveness and salvation

through Christ Jesus will continue to exist eternally in the presents of God in heaven. Those without forgiveness and salvation will be eternally

separated from God in hell. (John 3:16, Matt. 25:31, Rom. 6:23, and Rev. 20:15).

Baptism: Baptism is by immersion after conversion and a symbol of a relationship with Jesus Christ. Baptism does not make one a believer, but is

rather a reflection of one's obedience to Christ Jesus. (Matt. 28:19-20, Mark 1:9-11, and Acts 8:35-19).

The Church: The New Testament church of Jesus Christ is a local body of baptized believers who are covenanted together by the fellowship of the

gospel. The church observes two ordinances: baptism and the Lord’s Supper. The church is an autonomous body operating through democratic

processes under the Lordship of Jesus Christ. The Bible also speaks of the church as the body of Christ, which includes the redeemed of all ages.

(Matt. 16:15-19, Matt. 18:15-20, Acts 1:21-26, Acts 6:1-6, and Eph. 1:22-23).

The Home: In addition to these important beliefs, we also believe that God has given the parents and the home the responsibility to bring up their

children in the nurture and admonition of the Lord. (Eph. 6:4, and Prov. 22:6). We believe that a consistent and whole education will occur when

home, church and school work closely together and are in agreement on the basic concepts of life.

Thank you for reading these basic beliefs. Even if some of these are not your personal beliefs, we feel it is very important for you to know what

our school believes and what your child will be taught.

Both parents / guardians MUST sign:

_______________________________ _______________________________

FATHER/GUARDIAN SIGNATURE MOTHER/GUARDIAN SIGNATURE

_______________________________ _______________________________

DATE DATE

PARENT / GUARDIAN STATEMENT OF SUPPORT

Please read the following statements. If there is any statement you cannot personally support, please initial it and discuss it with us. If you are honest and

cannot support any one of these measures we would not necessarily prohibit acceptance into Maryville Christian School / Maryville Christian High School;

however, we want you to know from the start the foundational premises of Maryville Christian School / Maryville Christian High School, our parental

expectations, and how important it is to have your personal support.

1. We have received and read the “Statement of Doctrinal Beliefs” of the school and are willing to have our child(ren) educated in

accordance with them.

2. We agree to support, to the best of our ability, the school’s entire program through prayer.

3. We will worship the Lord regularly at a Bible believing church.

4. We will fully cooperate in the educational activities of Maryville Christian School / Maryville Christian High School by doing our best to

make Christian education effective in the lives of our child(ren).

5. We will require our child(ren) to support the spiritual activities of the school. (Chapel, bible classes, Scripture memory, etc.)

6. We will pay all of our financial obligations to Maryville Christian School / Maryville Christian High School on or before the date due. If we

are ever unable to do so, we will notify the director, giving a reasonable explanation for the delay and stating when payment will be

made.

7. The school reserves the right to place our child(ren) at the appropriate grade level and designate the appropriate teacher(s).

8. We will volunteer for duties and responsibilities for Maryville Christian School / Maryville Christian High School as opportunities arise and

God provides the time and strength.

9. We will be faithful to attend all parent functions at Maryville Christian School / Maryville Christian High School, as best we can. These

include open house, parent teacher/conference, etc.

10. If we become dissatisfied with Maryville Christian School / Maryville Christian High School in any way we will strive to resolve the matter

with the person(s) involved as privately and lovingly as possible, rather than spreading criticism, gossip and negativism. (Matthew 18:15-

17; 5:23-24)

COVENANT

A covenant is a binding agreement between two parties. It signifies a solemn oath and sincere pledge of mutual respect and cooperation. MCS / MCHS

covenants to provide the best it can for your child(ren) in the way of facilities, curriculum, faculty, social functions, and instruction. We further pledge to do

everything possible to support your home in growing every student in the nurture and admonition of the Lord. As the legal parents (guardians) of our

child(ren), we agree to support MCS / MCHS in its efforts at Christian Education. We agree that it is our responsibility to strive diligently toward the

observance of the “Parent / Guardian Statement of Support” as God enables us by the power of the Holy Spirit. Together, as a school and as parents

(guardians), we pledge to submit our lives to one another and to the final authority of the Word of God.

Both parents / guardians MUST sign:

_______________________________ _______________________________

FATHER/GUARDIAN SIGNATURE MOTHER/GUARDIAN SIGNATURE

_______________________________ _______________________________

DATE DATE

Illinois State Board of Education

New U.S. Department of Education Race and Ethnicity Data Standards

Student’s Name: _____________________________________ SIS ID: _________________ Date: _________________

Part A. Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central

American, or other Spanish culture or origin, regardless of race.)

Choose only one.

No, not Hispanic/Latino

Yes, Hispanic/Latino

The question above is about ethnicity, not race. No matter which answer you selected, continue and respond to the question below by

marking one or more boxes to indicate what you consider this student’s race to be.

Part B. What is the student’s race? Choose one or more.

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South

America, including Central America, and who maintains tribal affiliation or community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent

including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and

Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam,

Samoa, or other Pacific Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

Illinois State Board of Education Immigrant Student Enrollment Information

______________________________________ ____________________________________________

Student’s Date of Birth Country of Origin

______________________________________ ____________________________________________

Length of time enrolled in any U.S. School Language(s) spoken in the home

INSTRUCTIONS: This form is to be filled out by the student’s parents or guardians, and both questions must

be answered. Part A asks about the student’s ethnicity and Part B asks about the student’s race. If you decline to

respond to either question, the school district is required to provide the missing information by observer

identification.

Completion of the following information is required for those students who meet the “Immigrant Student” criteria as outlined

below. This information is required for State Reporting purposes.

(The definition of immigrant student is: any eligible student, age 3-21, who was NOT born in any of the 50 states, the District

of Columbia, Puerto Rico, or the US Virgin Islands and who has been attending schools in the U.S. for LESS than 3 full

academic years)

Maryville Christian School P.O. Box 579 Maryville, Illinois 62062 618-505-7000, ext. 500 fax 618-505-7005

KINDERGARTEN QUESTIONNAIRE CONSENT

I hereby give consent for the below named school or institution and its faculty to complete a Kindergarten Readiness

Questionnaire from Maryville Christian School.

School or Institution

__________________________________________ _________________________________________

School Phone

__________________________________________ _________________________________________

Address Fax

__________________________________________ _________________________________________

Teacher

For the following student(s):

__________________________________________ ___________

Student Age

__________________________________________ ___________

Student Age

__________________________________________ ___________

Student Age

Please return in self-addressed envelope to:

Maryville Christian School

P.O. Box 579

Maryville, IL 62062

618-505-7000 x 500

618-505-7005 / fax

_____________________________________________ _________________________________________

Signature of Parent/Guardian Date

_____________________________________________

Name of Parent/Guardian (please print)

_____________________________________________ _________________________________________

Signature of School Representative Requesting Records Date

Maryville Christian School P.O. Box 579 Maryville, Illinois 62062 618-505-7000, ext. 500 fax 618-505-7005

CONSENT FOR RELEASE OF SCHOOL STUDENT RECORDS

I hereby consent to the release of the following information from the school student records: Student records, including

identifying information, academic records, test results, attendance records, special service reports, health records, birth

certificate, behavior reports, psychological, referral and evaluations, and all other school records on file.

Records are requested from the following school:

__________________________________________ _________________________________________

School Phone

__________________________________________ _________________________________________

Address Fax

__________________________________________

For the following student(s):

__________________________________________ ___________ _________________________

Student Age Grade Attended at Prior School

__________________________________________ ___________ _________________________


__________________________________________ ___________ _________________________


Please forward records to:

Maryville Christian School

P.O. Box 579

Maryville, IL 62062

618-505-7000 x 500

618-505-7005 / fax

_____________________________________________ _________________________________________

Signature of Parent/Guardian Date

_____________________________________________ _________________________________________

Signature of School Representative Requesting Records Date

FOR OFFICE USE ONLY

_____________________________________________ _________________________________________

Date Records Requested: Date Records Received:

Documents

Student Name: Parents/Guardians Name: 2017-2018 … · Student Name: Parents/Guardians Name: 2017-2018 ... The following individuals are authorized to pick my child up from ... Jesus