New Beginnings Christian Academy

New Beginnings Christian Academy

Student Enrollment Form

School Year: 2006 – 2007

Today’s Date:
Requested Start Date Withdrawal Date:

Child’s Name: Last First M.I. Nickname

Complete Address:
Street City ST Zip

Gender: Birthdate: Social Security#: / /

Religious affiliation: Language(s) spoken at home

How did you hear about us?

Current Day Care Location

Previous School(s) Location

Family Information

Parent/Guardian Parent/Guardian

Name

Address

Home phone

Cell

Home Email

Employer

Work Phone

Work Email

Child’s Living Arrangements: ( ) Both Parents ( ) Mother ( ) Father ( ) Other

Child’s Legal Guardian(s): ( ) Both Parents ( ) Mother ( ) Father ( ) Other

Address & phone numbers of legal guardian (if different from parents)

To whom should correspondence be addressed?

Comments or other important information:

New Beginnings Christian Academy

Child’s Name:

Child’s Physician or Clinic’s Name (Primary health source):

Physician Telephone: Location:

r Check here if NO KNOWN ALLERGIES

My child has the following special need(s) and/or allergies:

These special accommodations(s) may be needed to meet my child’s needs while in the care of NBCA:

My child is currently under a physician’s care and on medication(s) prescribed for long-term, continuous use and/or has the following illness or health concerns:

Please list the first names and ages of all siblings of the child, and the schools they attend:

Other Information

Upon enrollment, may we share your name/address/phone number with other enrolled families? (check one) qYes qNo

Other comments or information of importance concerning my child:

New Beginnings Christian Academy

Child’s Name:

EMERGENCY CONTACTS

Person to contact in case of an emergency if parents cannot be reached (a local contact must be available):

Name Phone______________ Relationship_________________

Other persons authorized to pick up your child: (PLEASE INCLUDE THEIR PHONE NUMBERS)

Persons who may not pick up your child:

Do you have a court order pertaining to your child? (copy required)

SIBLING REDUCTION

For each additional child in the same family, the program fees will be reduced by $ per month.

LATE PICK UP FEES AND PROCEDURES:

It is important that children are picked up on time. We allow a 5 minute grace period, then we will charge $1.00 per minute. Maximum late fee (at 30 minutes) will be $25.00. After this point, we will attempt to notify all emergency contacts provided. If arrangements have not been made after 20 additional minutes, local authorities will be contacted.

PAYMENT SCHEDULE:

Tuition payments are to be paid on the 1^st of each month (except the first payment, which will be due when school begins). Make all checks payable to: New Beginnings Christian Academy. A $5.00 late fee for each week overdue will be assessed to all late payments. Any tuition payments that are overdue more than three weeks will lead to removal of the child from the program until full payment is made.

IMPORTANT, PLEASE READ CAREFULLY: CERTIFICATION BY PARENT; I CERTIFY THAT HAVE LEGAL AUTHORITY TO ENROLL THE APPLICANT CHILD NAMED HEREIN, AND THAT THE INFORMATION CONTAINED IN THIS FORM IS TRUE AND CORRECT IN ALL RESPECTS; UNDER PENALTY OF PERJURY. I UNDERSTAND THAT DLIBERATE MISREPRESENTATION OR WITHHOLDING OF INFORMATION MAY RESULT IN PROSECUTION UNDER APPLICABLE STATE AND FEDERAL STATUTES.

IMPORTANT. PLEASE READ CAREFULLY: I ALSO HEREBY ACKNOWLEDGE THAT THE CURRICULUM UTILIZED IN THIS PROGRAM IS BASED UPON THE DOCTRINE OF THE CHRISTIAN FAITH CONTAINED IN THE HOLY BIBLE, AND THAT MY CHILD WILL RECEIVE TEACHING THAT WILL INCLUDE BIBLICALLY-BASED CHRISTIAN PRINCIPLES.

SIGNATURE: DATE:
LEGAL GUARDIAN