Registration Packet

Registration Packet

2021-2022
Student's Name *

First Name Middle Name Last Name
Preferred Name *
Social Security Number *
Birthday *

Month Day Year
Grade Level Applying For *
Seeking *

Full Time Part Time/Home School
Address *

Street Address

Street Address Line 2

City State

Zip Code
Student's Cell Phone Number
Religious Affiliation *
Child Resides With *

Father and Mother Father Mother Grandparents Other
Sex *

Male Female
Race *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Most Recent School Attended *
Has the student ever been suspended/expelled from another school? *

Yes No
Has the student ever been retained at any grade level? *

Yes No
Has the student ever been diagnosed with dyslexia? *

Yes No
Has the student ever been diagnosed with ADD/ADHD? *

Yes No
If the answer is "YES" to any of the questions above, please explain. *
For new students, who referred you to UPA or how did you hear about our school? *
PARENT/GUARDIAN INFORMATION
Father's Name

First Name Last Name
Father's Email Address
Father's Cell Phone Number
Father's Employer
Father's Work Number
Father's Occupation
Father's Religious Affiliation
Father's Educational Level
Father's Marital Status

Married to Student's Mother Widowed Divorced Remarried Single
Mother's Name

First Name Last Name
Mother's Email Address
Mother's Cell Phone Number
Mother's Employer
Mother's Work Number
Mother's Occupation
Mother's Religious Affiliation
Mother's Educational Level
Mother's Marital Status

Married to Student's Father Widowed Divorced Remarried Single
Other Parent/Guardian/Custody information (including step-parents) school needs to be aware of--please provide court documentation if applicable.
EMERGENCY CONTACT INFORMATION
Student's Name *

First Name Last Name
Student's Birthday *

Month Day Year
Date
ALTERNATIVE EMERGENCY CONTACT (After Parents)
Emergency Contact #1 *

First Name Last Name
Contact #1 Phone Number *
Contact #1 Relationship to Student *
Emergency Contact #2 *

First Name Last Name
Contact #2 Phone Number *
Contact #2 Relationship to Student *
Student's Known Allergies
Other Medical Needs of Student
Student's Primary Physician *
Student's Primary Physician Phone Number *
Student's Preferred Hospital *
Student's Preferred Hospital Phone Number *
Student's Dentist *
Student's Dentist Phone Number *
All medical and surgical treatment or other medical and/or hospital procedures may be performed or prescribed by the attending physician and/or paramedics for my child and I waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in case of an emergency. *

I authorize the above statement I DO NOT authorize the above statement
By signing below, I agree that all information provided on the preceding pages is correct and agree to notify the school office in writing with any updates/changes to the information provided. *

Clear
By signing below, I agree that all information provided on the preceding pages is correct and agree to notify the school office in writing with any updates/changes to the information provided.

Clear
Date *

Month Day Year
Date
Date

Month Day Year
Date
PICK-UP AUTHORIZATION

In the event that a parent or emergency contact cannot pickup the student, the following people are given authorization to pick the student up from school.
Person #1

First Name Last Name
Phone Number
Relationship to Student
Person #2

First Name Last Name
Phone Number
Relationship to Student
By signing below, I agree that all information provided on the preceding pages is correct and agree to notify the school office in writing with any updates/changes to the information provided.

Clear
By signing below, I agree that all information provided on the preceding pages is correct and agree to notify the school office in writing with any updates/changes to the information provided.

Clear
Date

Month Day Year
Date
Date

Month Day Year
Date
PARENT AGREEMENT
Student Name *

First Name Last Name
Please read the following guidelines, then sign and date below.

I hereby give permission for my child, named above, to participate in activities of the normal school day, field trips, enrichment activities, after-school activities and electives. Parents will be notified about all special events, but an additional permission/signature will NOT be required. I understand that Union Pointe Academy is a school based on Christian values and beliefs. I agree to follow policies, procedures and regulations of Union Pointe Academy listed in the Union Pointe Academy handbook. I give permission for Union Pointe Academy faculty and staff to administer first aid and minor health care, prescription and non-prescription medication if parent approval has been given and signature is provided. I give permission for emergency care to be given by the child’s physician and hospital. A “Consent to Dispense Medication” form must be signed by the parent and filed in the office of Union Pointe Academy. I understand that all registration and technology/supply fees are not refundable and are paid each year of attendance. I understand that if I choose to make multiple tuition payments they are due on the first day of each month. Late fees will be charged after the 10th day of each month if payment is not made. I understand and agree with the dress code as described in the handbook. There are NO exceptions to the dress code. I agree to support the faculty and staff as authorities when enforcing procedures and policies at the school. It will be our practice to speak of the school in a positive manner. If we have a disagreement on policy of action, we will address our concerns with the persons involved. It will be the policy of UPA to share information regarding upcoming events, field trips and activities, pertinent information for the school day (weather related delays or closings) and school year in general on the UPA Calendar. I agree to check the website and calendar regularly. UPA will continue to send information using mass text thru the REMIND app. All families will be expected to sign up and utilize the system.
Parent Signature *

Clear
Date *

Month Day Year
Date
Parent Signature

Clear
Date

Month Day Year
Date
PARENT CONSENT
Student Name *

First Name Last Name
Please read the following for Consent to Photograph or Videotape, then choose which option you prefer and authorize it by signing and dating below.

I hereby give permission for my child, named above, to participate in interviews, quotes and taking of photography or video by Union Pointe Academy teachers, staff or designated adult. I grant UPA the right to edit and use said products for non-profit use in print and all forms of media. I release UPA and its’ employees from all claims and liabilities in connection with the above.
Please select one: *

Yes, I authorize permission No, I DO NOT authorize permission
Parent Signature *

Clear
Date *

Month Day Year
Parent Signature

Clear
Date

Month Day Year
STATEMENT OF ACADEMIC INTEGRITY
Student Name *

First Name Last Name
Please read the following guidelines, then sign and date below.

All classwork and assignments must be completed by the student An online assessment can only be completed at school, except during times of Remote Learning and must be unlocked by the teacher. Students must not copy work from another student. Students must sign an agreement regarding appropriate computer use in the classroom. (See separate Student Agreement, to be signed by both Student & Parent) As a Union Pointe Academy student, honesty is expected in all circumstances. All assignments must be composed by the student and not copied from any other source. Lying, plagiarism, and forgery will result in a zero for the assignment. Examples of these include, but are not limited to, copying and pasting answers from the internet, turning in any work not completed by the student, or copying another student's work. When representing Union Pointe Academy, students must be truthful about their work, grades and credits. Technological devices (cell phones, calculators, cameras, etc.) can only be used when directed by the teacher. Accommodations may be allowed if the teacher approves.
Parent Signature *

Clear
Parent Signature

Clear
Student Signature *

Clear
Date *

Month Day Year
Date
Student Agreement

Use of Computers, Software, Equipment and Access Information
Student Name *

First Name Last Name
Please read the following guidelines, then sign and date below.

Computers must be charged and ready for use every day. If a computer is not charged or is left at home, UPA will loan the student one of our school computers for a charge of $5 per day. Computer care is the responsibility of the student and parent. I will only use software my teacher has granted me the right to use. I will only visit websites that have been assigned by my teacher for the educational purposes. I will physically handle my computer with care. On the first day of school, I will be instructed on proper handling of my computer. I will not eat around my computer. I understand that I may drink only water during class time; however, water will only be allowed in a sturdy, covered, closeable, and non-disposable water bottle. I will take care not to spill water on or around my computer. I agree not to use my/UPA computer equipment, software, or programs for any purpose other than that for which it was originally intended. I agree not to copy, modify, or transfer any computer information or materials including items obtained via the internet, that I did not create without the express written consent of the original owner or copyright holder. I agree not to use my/UPA computers, software, systems, programs, products and documents to violate the terms of any software license agreement or any applicable local, state or federal laws. I understand that any violation of this agreement will require a conference with parent, student and teacher and may require disciplinary action. I understand that this agreement shall remain enforced as long as I use the computer equipment, software, systems and/or programs at UPA.
Parent Signature *

Clear
Student Signature *

Clear
Parent Signature

Clear
Date *

Month Day Year
Date
PARENT-STUDENT HANDBOOK SIGNATURE PAGE
Student Name *

First Name Last Name
Please sign below to signify your receipt and compliance with all expectations and the policies set forth in the Union Pointe Academy Parent-Student Handbook. Specifically, you have read the information contained within the Code of Conduct and agree to abide by the rules and support the provisions contained therein.
Parent Signature *

Clear
Parent Signature

Clear
Student Signature *

Clear
Date *

Month Day Year
Date
MISSION STATEMENT

To be a school for all students by partnering with parents to educate children to the full extent of their God-given abilities and potential and see them grow into young adults who positively impact society and the lives of others.
STATEMENT OF FAITH

UPA stands firm on the following foundational truths: We believe the Bible is the inspired, infallible, authoritative Word of God written under the inspiration of the Holy Spirit. We believe there is one God eternally existent in three persons - God the Father, the Son and the Holy Spirit. We believe in the deity of Jesus Christ, His virgin birth, His sinless life, His crucifixion and atoning death and glorious resurrection. We believe in His ascension to the right hand of the Father and His second coming. We believe that our salvation comes by God’s grace alone when we put our faith and trust in Jesus Christ as Lord and Savior.
Please read, check the box below, then sign and date. *

I have read and do support Union Pointe Academy's Mission Statement and Statement of Faith.
Parent Signature *

Clear
Date *

Month Day Year
Date
Parent Signature

Clear
Date

Month Day Year
Date
FINANCIAL SCHEDULE

When you enroll your child at UPA, a place is secured for your student for the entire school year. Based on this enrollment, UPA makes an annual financial commitment to hire faculty and staff, as well as to pay for day to day operating expenses. Tuition can be paid in three different ways (see below), however, when enrolling your student you are agreeing to be responsible for no less than 1 quarter's tuition which equals 3 months of payments. If you withdraw your child during the quarter, you are required to pay the remaining amount due in full for that quarter before any records will be released. A 30-day written notice of withdrawal is required.
Please read about UPA Tuition Rates for 2021-2022.

Grades K-6 $8100 (Full-Time) Grades 7-12 $8600 (Full-Time) Grades 9-12 $1600 per Credit Hour (Part-Time Homeschool Students) Grades K-8 $6400 (Part-Time Homeschool Students) Additional Child Discount of $500 (Full-Time students only)
Please read about UPA Student Fees. All fees are non-refundable.

Registration Fee--$225 Curriculum and Licensing Fee--$350 Senior Graduation/Class Fee--$150 Equipping Minds Fee (Optional grades K-8)--$65 Orton-Gillingham Fee (Full-Time Students)--$100 Orton-Gillingham Fee (Part-Time Students)--$1000 Late Fee on Tuition Payments--$35 Returned Check Fee--$25 At times during the school year, special events or activities may involve additional expenses. Most of these extra expenses will be optional, and every effort will be made to keep them to a minimum.
Please read how payments can be made:

Online, auto-draft banking provided by your financial institution Credit/Debit card payments through UPA's website Mailing a check to P.O.Box 1079, Union, KY 41094
Please indicate your choice below for UPA Tuition Payment Method: *

1 Payment. The student's tuition will be paid in full. Families who choose this option will receive a $200 Discount. This applies to FULL-TIME students only. 3 Payments. The student's tuition will be paid by the first of every month, for months September, December, and March. 9 Payments. The student's tuition will be paid by the first of every month, for months September-May. A fee of $25 will be added to each payment.
Please check the box, then sign and date below. *

I have read and fully understand that by registering my student(s), I am responsible for all tuition and fees as set forth above. All tuition and fees are non-refundable except for those who have paid tuition in full. Then the amount returned will be based off of the remaining quarters left in the school year.
Parent Signature *

Clear
Date *

Month Day Year
Date
Parent Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Registration Packet

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

ALTERNATIVE EMERGENCY CONTACT (After Parents)

PICK-UP AUTHORIZATION

PARENT AGREEMENT

PARENT CONSENT

STATEMENT OF ACADEMIC INTEGRITY

Student Agreement

PARENT-STUDENT HANDBOOK SIGNATURE PAGE

MISSION STATEMENT

STATEMENT OF FAITH

FINANCIAL SCHEDULE