BROCKTON SDA APPLICATION TO RETURN GRADES (PK, K, 5TH, 8TH)

Brockton Area Seventh-Day Adventist Academy

243 Court Street - Brockton, Massachusetts 02302
APPLICATION TO RETURN

Pre-Kindergarten – Eighth Grade
CHOOSE YOUR CHILD GRADE TO RETURN
Date:

MonthDayYear
Date
Directions: Complete all sections and return to the above address with medical records
PLEASE PRINT CLEARLY
STUDENT INFORMATION:
Name

Last NameMiddle NameFirst Name
S.S.N.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Date of Birth:

MonthDayYear
Date
Grade Applying for:

MEDICAL INSURANCE
Name of Company
Policy Number
Subscriber’s Name
MEDICAL RELEASE

If in the event of an accident during this school year, it becomes necessary for my child to receive medical/dental attention, I authorize Brockton SDA Academy, 243 court St. Brockton, MA staff to obtain emergency medical/dental care for my child. This care may be given under whatever conditions necessary to preserve the life, limb, or wellbeing of my child. I give permission for an ambulance to the nearest hospital. Payment for any treatment is the financial responsibility of the parent or guardian.
Signature
Date

MonthDayYear
Date

FINANCIAL AGREEMENT

I/We agree to assume responsibility for the timely payment of the tuition and other charges of pupil(s) listed above. I understand that the tuition for each student is expected by the 5th of every month. The grace period is between the 6th and the 10th of each month. A late fee of $35.00 will apply to any payment posted after the 10th of the month.
Application Fee
Categories:All

All

PK AND K

5TH
prevnext( X )
Grade 8
$200.00



PK AND K

Grade Pre-K and K
$100.00 Quantity



5TH

Grade 5
$150.00 Quantity
Item subtotal:$0.00



Total

$0.00
Parent/Guardian

First NameLast Name
Signature of Parent/Guardian
Date

MonthDayYear
Date
Should be Empty:

APPLICATION TO RETURN