Dayspring Christian Academy (K-5) Student Application

Dayspring Christian Academy (K-5) Student Application
Student Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
MaleFemale
Grade To Enter*
Step Up For StudentsFESHope Recipient

FAMILY INFORMATION
FatherStepfatherMotherStepmotherOther
FATHER/STEPFATHER
Title/Name:*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Occupation*
Work Phone & Ext:*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOTHER/STEPMOTHER
Title/Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Occupation*
Work Phone Number and Ext:*
Please enter a valid phone number.Format: (000) 000-0000.
It is the responsibility of the parent/legal guardian to support denial of parent access requests with court-ordered documentation regarding custody and/or revocation of parental rights.

EDUCATIONAL/ BACKGROUND INFORMATION
Student's Current School*
Current School Address:*
School Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
HomeschoolPrivatePublic
Number of Years Attended*
YesNo
If yes, which grade(s)?*
Has your child ever been suspended, expelled, or asked to withdraw form their present school for any reason? If yes, please explain.*
YesNo
If so, please provide details of the diagnosis.*
YesNo
If yes, please describe the medication and its effects (i.e.; improves concentration and focus, prevents headaches, controls mood, etc.):*

Parent-School Agreement
I/We agree to support and abide by school regulations and guidelines not only at
the time of admission but also throughout subsequent years of attendance. I/We authorize DCA to contact current and previous schools and other sources to obtain information tosupport this application. I/We will not seek access to confidential recommendations and evaluation materials before or after the admissions decision has been made.

I/We agree:
1. To support the standards of the school in every area of its policies and proceduresacademically, behaviorally, spiritually, in dress and in discipline.
2. To support the school in its endeavors in training my child in the Christian faith by
example, prayerful encouragement, Chapel and Bible classes.
3. To assume the responsibility for my child’s education by supervising assigned
homework and initiating contact with my child’s teacher.
4. To be involved in my child’s education through attendance and participation in the
various activities of the school, including all meetings held for parents.
5. I understand that all recommendations and forms are required to complete the
application process.
Statement Of Cooperation
I give permission for my child(ren) to take part in all school activities, including bus trips, sports activities, and school-sponsored trips away from the school premises. I also believe that discipline is necessary for the welfare of each student, as well as for the entire school body. I further agree to hold the school, its agents and Dayspring Baptist Church harmless for the liability of my child(ren) or any guardian or parent thereof because of any claims on behalf of my child(ren) against the school or any agent thereof because of any injury or alleged injury to my child(ren).
Should legal action for any reason, be taken against Dayspring Christian Academy or any employee or agent thereof, on my child(ren)’s behalf and the school or its agent not found to be at fault, I agree to pay any attorney fees, court fees, damages or other costs that Dayspring Christian Academy or its agent(s) should incur to defend itself against such action.

This Statement of Cooperation will be in effect for as long as my listed child(ren) attends Dayspring Christian Academy. I understand that should my marital status
change, it is my responsibility to have an updated Statement of Cooperation signed anddelivered to Dayspring Christian Academy. Dayspring admits students of any race, color, andnational or ethnic origin.
Signature Acknowledging You Have Read Parent-School Agreement & Statement of Cooperation*

Powered by Jotform SignClear
Date*

MonthDayYear
Date

MEDICAL HISTORY
Student Name*

First NameLast Name
Grade*
Does your child take medication regularly? Y/N. If so, please list medications(s) and the effects on your child's ability to function in school:*
Please list any medical conditions of which school personnel should be aware (e.g ADD, ADHD, Asthma, etc.):*
Please list any known allergies:*
EMERGENCY MEDICAL AUTHORIZATION/LIABILITY RELEASE The above-named child is presently attending Dayspring Christian Academy. He/she has the following physical or medical limitations, including allergies and prohibited medicine:*
Insurance Company: FILL IN field. Policy/ID#:FILL IN I hereby authorize and consent for Dayspring Christian Academy’s staff to employ a licensed physician on my behalf for the emergency treatment of my child, in connection with any injury, accident or illness suffered or sustained while involved in a school activity or while on school property. Said authorization and consent for emergency treatment includes hospitalization and surgical procedures recommended by physician. I understand that every reasonable effort will be made to notify me in case of such an emergency. I do hereby release Dayspring Christian Academy from any and all medical or hospital expense resulting from any type of accident or injury occurring to my child while involved in any school activity on or off campus.
Signature Signature Acknowledging You Have Read Medical History*

Powered by Jotform SignClear
Date*

MonthDayYear
Date

AUTHORIZED PICK-UP PERSON(S)

The following people are emergency contacts and authorized to pick-up or sign my child out from school. No one else is permitted to do so unless I notify the school in advance:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship *
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Relationship*
FINANCIAL POLICIES
Self-Paying Parents
Parent Accounts are established for each family enrolled at the academy. We accept cash, checks,cashier’s checks, money orders, and credit cards. All tuition payments are due by the first of the month and are late if received after the 5th. Payments made after the close of business on the 5th will incur a $50 late fee per child. If tuition payment has not been received within 15 days following the five-day grace period, as of the 16th day, the student(s) will not be permitted to class
until the parent account is brought current. Students whose tuition has remained unpaid for 30 days will be automatically withdrawn from the academy.

Scholarship Recipients (Step Up for Students, Hope, FES, AAA, Gardiner, and McKay)
Scholarship Tuition payments are distributed four times during the school year by the Step Up For Students, AAA, Gardiner, John McKay and Hope Scholarship programs. Though distributed by a third party, parents must be mindful that these scholarship payments cover the recipient’s tuition and fund their student’s enrollment at Dayspring Christian Academy. All parents of scholarship recipients are required to endorse the scholarship check within two (2) business days of receiving
text and/or email notification. Failure to endorse checks by the close of business of the second signing day will result in a $50 per child late check signing fee. If the scholarship recipient’s check has not been endorsed for 15 days following the signing period, as of the 16th day, the student(s) will not be permitted to class until the scholarship check is signed. Students whose scholarship check has remained unsigned for 30 days will be automatically withdrawn from the academy.

FINANCIAL OBLIGATION AGREEMENT

Self-Paying Parents
• I understand that tuition is due by the first of the month and are late if received after the 5th. Payments made after the close of business on the 5th will incur a $50 late fee per child.
• I further understand that failure to pay within the due dates prescribed above will
ultimately result in my student’s withdrawal from the academy.
Scholarship Recipients
• I understand that scholarship payments are distributed four times within the school yearand require my signature.
• I further understand that I have 2 business days from the time of notification to endorsepayment, or a $50 late fee per child will be charged to my account. Failure to sign within the due dates prescribed above will result in my student’s withdrawal from the academy.
Signature Acknowledging You Have Read & Agree To Comply With Financial Policies*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

Dayspring Christian Academy (K-5) Student Application

Student Information

FAMILY INFORMATION

FATHER/STEPFATHER

MOTHER/STEPMOTHER

EDUCATIONAL/ BACKGROUND INFORMATION

Parent-School Agreement

Statement Of Cooperation

MEDICAL HISTORY

AUTHORIZED PICK-UP PERSON(S)

FINANCIAL POLICIES