2022-2023 BASDAA Application PK

Brockton Area Seventh-Day Adventist Academy

243 Court Street - Brockton, Massachusetts 02302
APPLICATION FOR ADMISSION

Pre-School – Pre-Kindergarten
Date:*

MonthDayYear
Date
Directions: Complete all sections and return to the above address with the following:

1. Medical Record

2. Recent Photograph of Applicant

3. Birth Certificate

4. Social Security Card

Applicant will be required to take and pass a placement test administered by BASDAA prior to admission.
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
Cell Phone

Area CodePhone Number
Date of Birth:*

MonthDayYear
Date
Age:
Age:
Place of birth:
Grade Applying for:*
Gender

MaleFemale
ETHNIC BACKGROUND

American Indian or Alaska NativeBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteAsianOtherHispanic

Siblings of Applicant:
Sibling # 1
Name

First NameLast Name
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
School Attending
Grade
Sibling # 2
Name

First NameLast Name
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
School Attending
Grade
Sibling # 3
Name

First NameLast Name
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
School Attending
Grade
Sibling # 4
Name

First NameLast Name
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
School Attending
Grade

STUDENT ACADEMIC DETAILS

Questionnaire
Please answer the following questions as completely as possible and be very specific.
1. What characteristics of Brockton Area SDA Academy interest your family, and why do you feel that our school is a good fit for your child?
2. BASDAA is dedicated to nurturing and encouraging student’s intellectual, artistic, social, physical, and spiritual abilities. What are your child’s strengths in these areas?
3. In what areas would you like to see your child grow?
4. Please describe your child’s interests, hobbies, talents, and awards in both academic and extracurricular activities.
Signature of Parent / Guardian *

Clear
Date*

MonthDayYear
Date

{name339}
{dateOf}
MEDICAL CONSENT
As the legal custodial parent or guardian of the above mentioned student, I hereby give my consent and authorize the Brockton Area SDA Academy, or the individual designated person specified by the principal to:
- Administer any non-prescription medication, which I will supply with my child’s name on it, in accordance with the written instructions on the label supplied by the drug company. The non-prescription medication I supply has not met the expiration date for use. (i.e. pain relievers, Midol, Advil etc.)
- Administer any filled prescription medication which I supply to the school that is properly labelled with my child’s name on it, in accordance with the directions for the administration of the medicine listed on the label of the vial or container by the pharmacist. It is my responsibility to monitor the medication whenever refills are necessary. Any change in prescription must be authorized in writing by the doctor, pharmacist or myself in order to be administered to my child. The prescription medication has not met the expiration date for use.
- I understand that the Brockton Area SDA Academy Principal or other employees of the school or anyone designated by the Principal will administer medication when my child reports to the office for prescription medication supplied by me.
Consent for Medical Treatment
As the parent, agency representative or legal guardian, I hereby give consent for the Brockton Area SDA Academy and aftercare program to provide all emergency dental or medical care prescribed by a duly licensed physician (M.D.) or dentist (D.D.S.) for {name193} . This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent. I give permission for ambulance transportation to the nearest hospital. Payments for any treatment are the financial responsibility of the parent or guardian.
Insurance Type*
Policy Number*
Subscriber’s Name*
Signature of Parent / Guardian*

Clear
Date*

MonthDayYear
Date

ADMISSION PROCEDURE
Interview Policy

Students will participate in a group interview an individual. Applicants are interviewed for approximately 60 Minutes. The School will inform parents of the interview results.
Grade Placement / Testing Policy

In order that your child will receive an enriched educational growth experience BASDAA, it is our desire that parents and / or guardians understand that the school reserves the right, after testing a student and counselling with parents and / or guardians, to change the grade placement to one where the student will experience greater academic success. The Brockton Area SDA Academy exists for the purpose of providing successful educational experiences for all students. Therefore, it is necessary for parents to understand and consent to work cooperatively with the administration and faculty to help your child excel in all areas of Christian and academic experiences.

As the parent and / or guardian of {name193} , I have read the policy governing grade placement for my child, and I pledge my full cooperation.
School Tour

A Mandatory BASDAA tour and presentation is scheduled for all families who have applied. You will be of the date.
Signature of Parent / Guardian*

Clear
I confirm that, to the best of my knowledge, the information provided in this form is correct. I have understood and agree to abide by all school rules including school discipline, tuition fee payment.
Date*

MonthDayYear
Date

{name339}
{dateOf}
TUITION AND FEES

Tuition and Fees for the School Year for the Brockton Area SDA Academy
Fees: Constituent Member / Non Constituent Member
Grade PS-PK
- Application Fee: $ 250.00
- Registration Fee: $ 970.00
- Monthly Tuition: $ 485.00 (8 Months)
- Year Total: $ 5,100.00
FINANCIAL AGREEMENT

ALL FEES ARE NONREFUNDABLE Signature: I/We understand the terms, conditions, and amounts of payment for registration, tuition, and other fees. I/We also understand that the monthly tuition is due the first day of the month, and a late fee of $35 will be charged after the 10th of the month. I/We have fully read and concur with the Statement of Cooperation listed below, and will fully comply with the rules and regulations stated here and in the current BASDAA Handbook. I/We are entitled to legal custody of the child listed on this application and are authorized to sign all forms regarding this child.
Individual responsible for the account
Parent Signature *

Clear
Date*

MonthDayYear
Date

{name339}
{dateOf}
AUTHORIZATION FORM

Due to state requirements, a parent or guardian must authorize several items annually. Please check the boxes indicating your consent and sign on the space provided at the bottom of the page. If you have any questions concerning the items listed, please ask for assistance.
Library

My child has permission to check books out of our school library during the school year. I will be responsible for lost or damaged books and replacement costs.
Home and School Association Student Directory

The BASDAA HSA has permission to include my child’s information in the student directory. The following information will be included: The names of all students by classroom, parent’s, name, address, e-mail address and phone number.
School Web Site-News Media

I give permission for my child’s name, picture, work and school-related information to appear in television broadcasts, Northeastern Conference School District website and to be released to the media when appropriate, which includes the web sites of our individual schools.
BASDAA Student of the Week

Elementary students take part in the Student of the Week program. In order for your child’s photograph to be published in the BASDAA Bulletin Board, this selection must be checked.
Acceptable Use Policy

As a parent or legal guardian of the minor student listed below, I grant permission for my son/daughter to access BASDAA networked computer services, including local area networks, wide area networks, and internet access. I understand that individuals and families may be held liable for violations of the forgoing acceptable Use Policy. I understand that some materials on the Internet may be objectionable, but I accept responsibility for guidance of Internet use – setting and conveying standards for my son/daughter to follow when selecting, sharing or exploring information and media. I have discussed the terms of this authorization with my child.
I hereby agree to hold harmless BASDAA, its employees, agents, and Board members, from any harm caused by materials or software obtained via any BASDAA computer or Internet connection. I have been provided a copy of the BASDAA School Acceptable Use Policy.
Signature of Parent/Guardian *

Clear
Date*

MonthDayYear
Date
Brockton Area SDA Academy reserves the right to withdraw acceptance or dismiss the applicant from school in the event that incomplete or inaccurate information is provided. The application information is confidential and is intended for the school’s purposes only. This form is an application for admission only. Upon completion of all application procedures and Admissions Committee approval, you will be notified of acceptance.

We (I) affirm that the information provided in this application is true to the best of our (my) knowledge.
Signature of Parent/Guardian*

Clear
Date

MonthDayYear
Date

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM
Child's Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
I authorize staff in the Brockton Area SDA Academy who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date

FOR OFFICE USE ONLY

This Page is to be completed by the BASDAA registrar only. Continue to the next page.
Form Checked By:
Date

MonthDayYear
Birth Certificate ProvidedPhotograph ProvidedSchool Leaving CertificateMedical Records
Registration Fee Paid On:

MonthDayYear

Payment Methods:

	Fees
Cash:
Or Check No:
Credit Card:
Application Fee:
Tuition Deposit:
Total:

Constituent / Non-Constituent

CN
Signature

Clear
Note

Document To Upload
1. Medical Record

2. Recent Photograph of Applicant

3. Birth Certificate

4. Social Security Card
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Application Fee*
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Application Fee
$250.00

Graduation Fee
$100.00

Total

$0.00
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Brockton Area Seventh-Day Adventist Academy

APPLICATION FOR ADMISSION

PLEASE PRINT CLEARLY

STUDENT INFORMATION:

Siblings of Applicant:

Sibling # 1

Sibling # 2

Sibling # 3

Sibling # 4

STUDENT ACADEMIC DETAILS

Please answer the following questions as completely as possible and be very specific.

MEDICAL INFORMATION

MEDICAL CONSENT

Consent for Medical Treatment

ADMISSION PROCEDURE

Interview Policy

Grade Placement / Testing Policy

School Tour

TUITION AND FEES

Fees: Constituent Member / Non Constituent Member

Grade PS-PK

FINANCIAL AGREEMENT

STUDENT PICK-UP AUTHORIZATION FORM

Authorized Adult to Pick up Student

AUTHORIZATION FORM

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM

FOR OFFICE USE ONLY

Document To Upload