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

PK OR K 5TH 8TH
Date: *

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

Last Name Middle Name First Name
S.S.N. *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Date of Birth: *

Month Day Year
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

Clear
Date

Month Day Year
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.
Parent/Guardian *

First Name Last Name
Signature of Parent/Guardian *

Clear
Date *

Month Day Year
Date
Application Fee *
Categories: All

All
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Application Fee
$ 150.00

Graduation Fee GRADE PK , K
$ 100.00 Graduation Fee ( per grade )
Item subtotal: $ 0.00

Total

$ 0.00
Should be Empty:

APPLICATION TO RETURN