NCCLC Student Application Form

Current Date

Month Day Year
Date
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NCCLC Student Application Form

{typeA144}
Which CLC Class are you applying for? *
Student Information
Student Name *

First Name Middle Name Last Name Suffix
Student's Grade *
For the current school year.
Student's Phone #
Please enter a valid phone number.
Student's Email
example@example.com

Address Information
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Mail Address (If different from above)

Street Address

Street Address Line 2

City State

Zip Code

Parent/Guardian Information
Parent/Guardian 1 Name *

Prefix First Name Middle Name Last Name Suffix
Parent/Guardian 1 Phone # *
Please enter a valid phone number.
Parent/Guardian 1 Relation *
Parent/Guardian 1 Email *
example@example.com
Parent/Guardian 2 Name

Prefix First Name Middle Name Last Name Suffix
Parent/Guardian 2 Phone #
Please enter a valid phone number.
Parent/Guardian 2 Relation
Parent/Guardian 2 Email
example@example.com
Student lives with? *
Home Phone # *
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
Name of person to be contacted if Parent/Guardian cannot be reached *
I Give My Student *

First Name Middle Name Last Name Suffix
permission to attend class at The Christian Learning Center for the {typeA144} school term and for my student to correspond with CLC personnel throughout the week. I also give my student permission to be transported, when needed, in transportation provided by the CLC, and for my student

to walk with CLC personnel and designated chaperones to locations decided upon by CLC personnel.
Parent/Guardian Signature *

Clear

LIABILITY RELEASE AGREEMENT

Newton County Christian Learning Center
Minor's legal name: *

First Name Middle Name Last Name Suffix
Wishes to participate in class transportation, off-campus field trips, and other activities (“Activities”) sponsored by the Newton County Christian Learning Center (NCCLC) throughout this school year. NCCLC and the undersigned parent or legal guardian of Minor agree that the Activities may pose risks, including possible illness, injury, as well as similar and dissimilar risks (“Risks”). The undersigned is fully aware of the Risks and other hazards inherent in the Activities and is participating in the Activities voluntarily and assumes the Risks and all other risks of loss, damage, or injury that may be sustained while participating in the Activities.

CCLC makes no representations or claims as to the condition or safety of the land, structures, transportation or surroundings that may be involved in the Activities, whether or not owned, leased, operated or maintained by NCCLC. In exchange for allowing the Minor to participate in these NCCLC Activities, the Minor, by and through the undersigned, the undersigned, and their respective heirs, personal representatives and estates agree(s) to release from liability and hold harmless NCCLC and any agent, officer, employee, or volunteer of NCCLC acting within the scope of their duties for any injury to the Minor’s person or damage to the Minor’s property. I authorize NCCLC to take any action, including seeking medical care, necessary in its judgment if I am not present or reachable in the event of an emergency. The undersigned acknowledges that as a part of this Release he or she shall be 100% liable to pay for all medical expenses resulting or to result from any injury incurred during, or as a result of, participation in the Activities.

If any term of this agreement or the application to any person or circumstance shall, to any extent, be invalid or unenforceable, the remainder shall not be affected thereby, and each and every remaining term of this agreement shall be valid and enforced to the fullest extent permitted by law. In the event of any need to enforce this agreement, NCCLC shall be entitled to its attorney fees and costs. This agreement will be governed by Georgia law.

I, the undersigned, state that I am the parent or legal guardian of the Minor. I have fully read and understand the above terms and conditions and that they apply to said Minor and to myself, and that no oral representations, statements or inducements apart from the foregoing written agreement have been made to the undersigned. This document is binding on myself, the teacher, any volunteers, the said Minor, and any person suing on behalf of said Minor.
Name of Parent/Guardian *

Prefix First Name Middle Name Last Name Suffix
Parent/Guardian Cell Phone *
Please enter a valid phone number.
Name of Parent/Guardian 2

Prefix First Name Middle Name Last Name Suffix
Parent/Guardian Cell Phone 2
Please enter a valid phone number.
If Parent/Guardian cannot be reached, list two (2) Emergency Contacts who will assume care of your child:
Emergency Contact 1 *

First Name Last Name
Relationship *
Emergency Contact 1 Phone# *
Please enter a valid phone number.
Emergency Contact 2

First Name Last Name
Relationship
Emergency Contact 2 Phone#
Please enter a valid phone number.
Parent/Guardian Signature *

Clear

Transportation Agreement

Newton County Christian Learning Center
Middle School: For their safety and out of respect for the school environment, students must travel to/from NCCLC class in the NCCLC provided transportation.

CLC classes before school: The students will arrive at Oxford Baptist Church at the designated time. After the NCCLC class period is finished, the students will be
transported to Cousins Middle School prior to the beginning of first period. Students will need to board the van/bus in a timely manner so everyone will arrive at
school on time. Students failing to report before the van/bus departure will be required to have alternate transportation for one week.

CLC classes after school: The students will arrive at the designated pick up point at the designated time. The class will travel to First Baptist Covington with the
teacher via walking or CLC transportation. Students will need to board the van/bus in a timely manner so everyone will arrive at CLC on time. Students failing to
report before the class departure will be required to have alternate transportation for one week.
Students missing the bus for the third time will be required to have a teacher/parent conference. (Newton County School Requirements will be enforced.)

High School CLC: NCCLC is unable to provide unlimited CLC transportation from the public high schools located in Newton County to our CLC High School Class
hosted at First Baptist Covington. The limited CLC transportation provided will be filled on a first come, first served basis upon requesting a seat. Anyone wanting
to secure a seat on a transit should contact the Director. Students not riding CLC transportation will need to arrange transportation to the CLC Class on their own.

Occasionally, the CLC High School Class may take an off-campus field trip.
For their safety and out of respect for the CLC environment, students must travel in the designated manner assigned below for the NCCLC High School Class in the
NCCLC provided vehicle when special events/trips are planned.
All students are required to turn in signed permission to ride in the Newton CLC transportation. This is located on the Student Registration/Permission Form pg. 1
Passenger Rules:
1. Any objects considered illegal by Newton County School System (NCSS) are considered illegal by the Newton County Christian Learning Center and not
  allowed on the van/bus. These items include: knives, firearms of any kind, fireworks or explosives, tobacco products, drugs, alcohol, pagers or beepers,
  obscene items (books, magazines, pictures, etc.) Please refer to your respective school handbook for a more complete listing.)
2. No cell phones or electronic devices are to be used on the van/bus without permission from the NCCLC staff. Failure to comply can result in loss of
  student’s phone/device until retrieved by their parent from the staff.
3. Keep hands and arms inside the van/bus at all times.
4. Maintain normal voice levels.
5. Pick up any trash you have. Do not leave trash on the van/bus or throw on floor.
6. Wait your turn when entering or leaving the van/bus. No pushing or shoving.
7. Enter and exit the van/bus in a timely manner. Do not make yourself or others late.
Student's Signature *

Clear
Parent/Guardian's Signature *

Clear

Computer/Internet User Agreement

Newton County Christian Learning Center
It is our belief that the use of telecommunications, including the Internet, in instructional programs will facilitate communication, innovation, resource sharing, and access to information. Use of the Internet must be in support of education and research and consistent with the educational mission of the NCCLC.
Student Acceptance Use Policy:

I understand and will abide by the Christian Learning Center Acceptable Use Regulations governing student access to the Internet. I further understand that any violation of the regulations is unethical and may constitute a criminal offense. Should I engage in unacceptable activities as outlined below, my access privileges may be revoked, disciplinary action may be taken, and/or appropriate legal
action may be initiated.

Internet activities deemed unacceptable conduct and resulting in revocation of network privileges
include but are not limited to the following:
1. Use for any purpose that violates a federal, state, or local law.
2. Use for any for-profit activities.
3. Use for private business, including commercial advertising
4. Use for fund raising or public relation activities not specifically relate to NCCLC approved activities.
5. Use for any political activities.
6. Use to interfere with or disrupt network, users, services, or computer related equipment.
7. Use to intentionally seek out information on, obtaining copies of, or modifying files or data, which are confidential under federal, state, or local law.
8. Use to intentionally seek out information on, obtaining copies of, or modifying files or data belonging to others without authorization of thefile owner.
9. Use to intentionally make copies of any software, electronic file, program, or data using NCCLC provided equipment without a prior, good faith
  determination that such copying is, in fact, permissible according to copyright laws. Any efforts to obtain permission should be adequately documented.
  Copyright materials include text, pictures video, and audio.
10. Use to intentionally misrepresent himself/herself electronically as another person.
11. Use to intentionally develop computer media designed to harass other users, infiltrate a computer or computing system, and/or damage or alter the
  software components of it, or in any way hamper the operation of the system, i.e., a computer virus.
12. Use to send or download information that is offensive, harassing, or otherwise disparages others on the basis of any protected characteristic.
13. Use for, access to, and distribution of: Any sexually explicit or pornographic materials.
14. Material sent or received in violation of the Protection of Children against Sexual Exploitation Act of 1977 (U.S.C. 2252.)
15. Posting or plagiarizing work created by another person without their consent.
Student's Name *

First Name Last Name
Student's Signature *

Clear
Parental Agreement:

As the parent or guardian of this student, I have read and discussed with my child the Christian Learning Center’s Acceptable Use Regulations governing student
access to the Internet. I understand that this access is designed for educational purposes and that student access will be monitored. However, I also realize it is
impossible for the agencies involved to restrict all controversial materials, and I will not hold them responsible for materials acquired on the network. I hereby give
permission for my child to have Internet access.
Parent/Guardian's Name *

First Name Last Name
Parent/Guardian's Signature *

Clear

Student Publicity Release

Newton County Christian Learning Center
The Newton County Christian Learning Center is excited to be operating in our county. Throughout this school year, interesting or notable events will be shared with the community and possibly other educational agencies to honor our Lord, the Center, and the student. Student art, literary, and audio/video productions, which may or may not include the student’s photograph, will be used to publicize the Center and/or student achievement. Student work and student photographs (groups or individuals) will be presented. Home addresses, telephone numbers, or other personally identifiable student information will not be released or published in press releases, newsletters, or websites. I give my permission for the Newton County Christian Learning Center to publish my child’s work and image in newsletters, periodicals, newspapers, radio/TV broadcasts and websites.
Parent/Guardian's Signature *

Clear

Clinic Information Sheet

Newton County Christian Learning Center
Gender: *
Date of Birth *

Month Day Year
Date
Student's Name *

First Name Middle Name Last Name
Student's Grade *
For the 2021-2022 School Year
Homeroom Teacher's Name

First Name Last Name
Health History

Please answer the following *

	Yes/No	If Yes, Please Explain
Allergies
Asthma
Cancer
Diabetes
Drug Alergies/Reaction
Heart Problem
Kidny Problem
Migraine Headache
Physical Handicaps
Seizure
Skin Conditions
Other
My Child needs an inhaler at school
My Child requires an Epi-pen for sever allergic reactions
My child takes prescribed medications

Emergency Information
Parent/Guardian 1 Name *

Prefix First Name Middle Name Last Name Suffix
Parent/Guardian 1 Cell # *
Please enter a valid phone number.
Parent/Guardian 1 Home #
Please enter a valid phone number.
Parent/Guardian 1 Relation *
Parent/Guardian 2 Name

Prefix First Name Middle Name Last Name Suffix
Parent/Guardian 2 Cell #
Please enter a valid phone number.
Parent/Guardian 2 Home #
Please enter a valid phone number.
Parent/Guardian 2 Relation
If parents cannot be reached, list two (2) Emergency Contacts who will assume care of your child:
Emergency Contact 1 *

First Name Last Name
Relationship *
Emergency Contact 1 Phone# *
Please enter a valid phone number.
Emergency Contact 2

First Name Last Name
Relationship
Emergency Contact 2 Phone#
Please enter a valid phone number.
Parent/Guardian's Name *

First Name Last Name
Parent/Guardian Signature *

Clear
Email to send a copy of your application to *
example@example.com
Should be Empty:

NCCLC Student Application Form

Student Information

Address Information

Parent/Guardian Information

LIABILITY RELEASE AGREEMENT

Transportation Agreement

Computer/Internet User Agreement

Student Publicity Release

Clinic Information Sheet

Health History

Emergency Information