PIKE CHRISTIAN ACADEMY PRESCHOOL 2010/11
Student Application
Full time ______ approximate arrival time ______ Date of Application_____
Part time ______ approximate pick-up time _____ Date of Enrollment _____
M T W TH F ____Boy ____Girl
Student’s name____________________________Date of Birth_____________________
Address_________________________________________________________________
Student’s Social Security #________________________Phone_____________________
Church now attending____________________________Pastor_____________________
School District of Residence_________________________________________________
Last school attended_____________________________Address____________________
If parents are divorced or separated, who has legal custody of the child?_______________
Is either parent forbidden by court order from having equal access to the child or the child’s records? _____.
If yes, please submit written documentation with application.
Father’s name_______________________________Home phone___________________
Home address____________________________________________________________
Street City State Zip
Father’s occupation___________________Employer__________W. phone___________
Church father attends____________________________Pastor_____________________
Marital status____married____separated____divorced____widowed____single
Mother’s name_______________________________Home phone__________________
Home address____________________________________________________________
street city state zip
Mother’s occupation__________________Employer_____________W. phone________
Church mother attends____________________________Pastor____________________
Marital status____married____separated____divorced____widowed____single
Emergency Contacts: Beeper/cell phone: Father____________Mother____________
In the event a parent cannot be reached, please list three emergency contacts:
Name___________________Phone_______________Relationship________________
Address_______________________________________________________________
Name___________________Phone_______________Relationship________________
Address_______________________________________________________________
Name___________________Phone_______________Relationship________________
Address_______________________________________________________________
**ALL STUDENTS ARE REQUIRED TO HAVE A CURRENT SHOT RECORD AND MEDICAL STATEMENT ON FILE BY THE FIRST DAY OF SCHOOL. MEDICAL STATEMENTS ARE VALID FOR ONE CALENDAR YEAR FROM EXAM DATE.
Medical Information: 2010/11
Physician or Clinic_________________________________Phone_________________
Address________________________________________________________________
Dentist___________________________________________Phone_________________
Address________________________________________________________________
Allergies (foods, medications, environmental, etc.) _____________________________
______________________________________________________________________
If your child takes any medications, please list medication and reason taken
_______________________________________________________________________
Please list any health problems you wish the school to know.______________________
_______________________________________________________________________
Please check any of the following your child has had or currently has:
____Heart Disease ____Measles ____Rheumatic Fever _____Mumps
____Diabetes ____Tuberculosis ____Epilepsy ____Asthma
____Chicken Pox ____Other________________________ ____None
Release of Students:
It is the policy of Pike Christian Academy Preschool to excuse students to leave the school only with parents or legal guardians. If you want your son or daughter to be excused to leave with anyone other than yourself, please list their name, address, and phone number below.
Name Address Phone
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Your signature below indicates your approval.
___________________________________________ ___________________
Parent or legal guardian signature Date
Permission to Transport Child:
Complete either Part I or Part II below. Do not complete both.
Part I. Permission to transport child.
I give Pike Christian Academy my permission to transport my child, ________________
____________________, to _________________________(hospital/clinic) for
emergency medical or dental care, or to the nearest available source of assistance.
_________________________________ ______________________
Parent’s Signature Date
Part II. Refusal to grant permission to transport child.
I do not give Pike Christian Academy permission to transport my child, ______________
__________________, for emergency medical or dental care. In the event of an illness
or injury which requires emergency medical or dental treatment, I wish the child care
facility to take the following actions: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________ ________________________
Parent’s Signature Date
I would like my name and phone number listed on the parent roster (to be given to other parents only).
_____Yes _____No
__________________________________ ______________
Signature of Parent, Custodian or Guardian Date
Pike Christian Academy
Permission to transport (2010/11)
Field trips, practices
Each year, we transport our students to New Covenant Church to practice for the Christmas program and graduation/closing ceremonies for the 2010/11 school year. Please sign below, giving us permission to transport your child/children for these practices. This will eliminate the need to secure signed permission slips each time we do this.
I give permission for my children:
1.
2.
3.
4.
to be transported to New Covenant Church (or the designated practice spot) for the purpose of practicing for the Christmas program and graduation/closing ceremonies.
I will not hold the school or any volunteer driver responsible in the event of an accident.
____I am willing to help transport children to and from these practices.
____________________________Signature of parent(s)/guardian.
____________________________Date
MEDIA PERMISSION SLIP
2010/11
PCA often advertises in the newspaper, etc. We also like to submit articles, with pictures, about events that happen here at school. We may also desire to post school pictures on our school website. Please indicate your preferences below, giving us permission to use your child’s picture in our advertisement.
Thank You
_____________________
Student Name
I/We give permission for the above named student’s picture to be used in newspaper articles, advertisement, etc.
Please check only those media outlets that you approve.
____Newspaper advertisement
____Newspaper activity articles
____School web site postings
Signature of Mother
Signature of Father
Pike Christian Academy
Parent Agreement 2010/11
As a parent of a student enrolled in the Pike Christian Academy Preschool, I hereby agree to the following:
1. I have read and been given a copy of the Basic School Rules. I agree to support these rules and to do everything in my power to see that my child follows these rules.
2. I have read and been given a copy of the Discipline Policy. I agree to support the teachers and Administrator in the execution of discipline. I would like to request that __________________also be used in the discipline of my child in the following situations___________________________________________________________.
3. I have read and been given a copy of the Tuition and Fees. I understand that the PCA Preschool operates on a pre-pay basis and I will pay accordingly. I agree to pay tuition charges according to the designated schedule. I understand that registration and book fees are due before school starts, and that the first month’s tuition is due by September 1st.
4. I have read and been given a copy of the Statement of Faith. The beliefs therein are those which I also hold or would not oppose them being taught to my child.
5. I understand that the mission of Pike Christian Academy is to provide a
quality education without compromise to all seeking a Christ-centered environment; to challenge students to submit to the Lordship of Jesus Christ; and to motivate students to develop spiritually, intellectually, socially, culturally and physically. My signature below indicates that I am seeking a Christ-centered environment for my child’s education and I will cooperate with the school in accomplishing the goals of this mission in the life of my child.
____________________________________ _________________
Mother’s signature Date
____________________________________ _________________
Father’s signature Date
Failure to cooperate with the terms of this agreement will result in the
withdrawal of your child from Pike Christian Academy.
Pike Christian Academy
ONE-CALL NOW
Please list three phone numbers that you would like to have listed for the
one-call program. (Automated calling service alerting parents to: reminders of school events, school closings, early dismissals, school emergencies, etc.)
Phone # 1: ____________________________________________
Phone # 2: ____________________________________________
Phone # 3: ____________________________________________
Pike Christian Academy
Volunteer form 2010/11
___________________________________________Parent’s names
By filling out this form, you are not obligating yourself to a specific date or amount of volunteer time. This gives us an idea of areas that you, as parents,
are willing to help with. When it is time to prepare for a project, we can consult this list, and would call you to see if you can help at that time.
I am interested and willing to volunteer my time to help with the following
projects:
_____Box tops for education (parent organizer)
_____Harvest Banquet (set-up, clean up, serving, etc.)
_____Fair Booth (working shifts at the fair)
_____Helping with Room Parties
_____Yearbook (taking pictures, editing, etc.)
_____Annual Citrus Sale (unloading fruit, etc.)
_____Being a Chapel Speaker
_____Light Construction work around the school
_____Repair work: _____plumbing _____electricity
_____Snow removal
_____Painting _____carpet cleaning _____bush trimming
_____moving of furniture or other heavy objects
_____playground maintenance (spreading gravel, planting grass, etc.)
PIKE CHRISTIAN ACADEMY PRESCHOOL
Tuition and Fees 2010/11
Registration Fee: $40.00 per child
$55.00 per family
Book Fee: $30.00 - 3 & 4 year old class
$60.00 - Pre-Kindergarten Classes
Part Time: Part time is considered 3 full days or five mornings. Noon is the cut off time for half days. Fee is $240.00 per month, due at the 1st of each month beginning September 1st.
Additional days, if available, are $20.00 per day and additional half days
are $12.00.
Full Time: Full time is five full days. Fee is $340.00 per month, due at the 1st of each month beginning September 1st. Students registered as full-time students are expected to pay the full-time monthly rate.
PRE-PAY: All preschool accounts are on a PRE-PAY basis. Payment is due on the 1st of each month for that month. Any account not paid by the 5th of the month will result in your child not attending preschool until the account is paid in full.
HOURS OF OPERATION: We are open from 6:30 a.m. to 5:30 p.m. In the event that an emergency arises that keeps you from picking up your child on time (5:30) you will be charged $5.00 per child for up to 15 minutes late. For 16-30 minutes late you will be charged $10.00 per child. Repeated late pick-ups may result in withdrawal of your child from Pike Christian Academy.
MEALS: Lunch and 2 snacks (morning and afternoon) are included with tuition. If your child arrives before 8:00 a.m., you may send breakfast with him/her or you may purchase a bowl of cereal with milk for $0.50.
Pike Christian Academy Nondiscrimination Policy
“The governing board of the Pike Christian Academy school located at 400 Clough St in Waverly, Ohio, 45690 has adopted the following racial nondiscriminatory policies.”
“The Pike Christian Academy school recruits and admits students of any race, color or ethnic origin to all its rights, privileges, programs and activities. In addition, the school will not discriminate on the basis of race, color or ethnic origin in the administration of its educational programs and athletics/extracurricular activities. Furthermore, the school is not intended to be an alternative to court or administrative agency ordered, or public school district initiated desegregation.”
“The Pike Christian Academy school will not discriminate on the basis of race, color, or ethnic origin in the hiring of its certified or non-certified personnel.”
Pike Christian Academy
Basic School Rules 2010/11
The following list of school rules are those essential policies of which we require all our students to be aware and to which they are expected to adhere.
1. Students are expected to cooperate with basic Christian standards of
behavior, etiquette and conversation.
2. Teachers and staff are to be treated with respect. There should be no
talking back or arguing. Prompt and cheerful obedience is expected.
Requests from the teachers should not have to be repeated.
3. No chewing gum, video games, giga pets, guns, or knives or anything
that is determined to be a distraction from learning is allowed on
school grounds.
4. Students are expected to treat all of the school’s materials and
facilities, as well as the belongings of others, with respect and care.
This includes all text books distributed to students. (Parents will
be charged for lost or damaged books).
PIKE CHRISTIAN ACADEMY PRESCHOOL
DISCIPLINE POLICY 2010/11
The preschool teacher or latchkey provider is responsible for classroom discipline. The administrator will intervene when asked to do so or if a child exhibits any of the following behaviors:
1. Physically harming another child or staff member.
2. Disrespectful to other’s property or school property.
3. Deliberately disobeying instructions or school rules.
4. Disrespectful to a teacher or other staff member.
5. Inappropriate language.
Each classroom has posted a set of rules. Each child will be taught what they are and will be
expected to follow them. When disciplinary actions must be taken, it will be explained to the child what behavior was inappropriate and why.
Several forms of discipline are used. First, removing a child from the situation is known as time out. The child will be separated from the situation for a 10 minute period. Upon returning to activity, the child will explain the reason for time out.
Second, denial is used as another method. The child will not have the opportunity to play with or participate in activity taking place, and/or be with a particular person. The limited time frame will be determined by the severity and history of the inappropriate behavior. An explanation to the child will be offered as to the reason for being denied something.
Third, any consistent behavior problem will be brought directly to the parents and administrator’s attention by the care provider. A conference will be held to determine what other actions can be taken to hinder inappropriate behavior of the child.
Fourth, if a child’s behavior becomes detrimental to his health, other children, teachers or staff members, a child may be withdrawn from the preschool. Individual cases will be discussed with the board to suspend or terminate enrollment of the child.
Withholding food, drinks, sleep, or toilet facilities are not forms of discipline. No restraints, harsh or cruel techniques will be used. Children will not be placed in an enclosed area, such as a closet. Discipline techniques will not harm, embarrass or frighten a child.
Discipline is to correct inappropriate behavior at a given moment, but is also to help strengthen the desire to do what is right and good according to the standards of God’s Word. We want the child to understand why something is appropriate or inappropriate.
It is our desire to be an extension of the home. If a particular discipline works with your child at home and you would like for that discipline to be exercised at PCA, please explain on the parent agreement form, and within the limits of our policies, we will try to help you maintain the consistency of discipline you desire for your child.
Statement of Faith
The following is a list of doctrines and beliefs held to and taught at Pike Christian Academy:
1. The Bible is the only infallible, authoritative Word of God, and contains all that is necessary for our salvation.
2. There is one God, eternally existent in three Persons: the Father, the Son, and the Holy Spirit.
3. Jesus Christ is the only begotten Son of God. He was conceived of the Holy Spirit and born of the Virgin Mary. He was truly human (but without sin) and truly God. He performed miracles and made an atonement for our sins through his substitutionary death on the cross. He rose from the dead and ascended to the Father and He will return in power and glory to judge the living and the dead.
4. Salvation is by grace alone through faith in Jesus Christ.
5. Faith without works is dead.
6. All human beings are sinners and must be born again through the grace of Jesus Christ and the power of the Holy Spirit.
7. The Holy Spirit indwells Christians to equip them to live a godly life and build up the body of Christ.
8. All believers are spiritually one in Christ.
The redeemed of the Lord will experience a bodily resurrection and eternal life through Jesus Christ.
Illness Policy 2010/11
This policy shall be in effect for all students at Pike Christian Academy
(Preschool – Eleventh Grade). The purpose of this policy is to keep the transmission of illnesses among the children to an absolute minimum.
If your child has had vomiting, diarrhea, or fever of 100.0 or higher (that would be 99.0 under the arm) after 4:00 pm of the previous day, do not send them to school. If your child has gone to the doctor and has been prescribed an antibiotic, they may not return to school until they have been taking the antibiotic for at least 24 hours.
If your child has head lice, they may not return to school until all nits are removed from the hair, even if the child has been treated.
Please be informed that if your child becomes ill at school (vomits, develops a fever of 100.0 or higher, has diarrhea or head lice is found) you will be called and expected to pick up your child in a timely manner. We really do not have adequate space for taking care of a sick child and cannot leave the child in contact with the other children.
MEDICAL STATEMENT
2010/11
This is to certify that I have examined
(child’s name) _____________________________________________________________
DOB (month/day/year), _____________________ on ____________________________
Date
- Medical statement is not valid without a date
And have found that the child had the immunizations required by Section 3313.671 of the Revised Code for admission to school, or has had the immunization required by the state department of health for infants and toddlers or is to be exempted from these requirements for medical or religious reasons.
|
Vaccine for
|
Date
|
Dose 1
|
Dose 2
|
Dose 3
|
Dose 4
|
Dose 5
|
|
Diphtheria, Tetanus, Pertussis
|
|
|
|
|
|
|
|
Hepatitis B
|
|
|
|
|
|
|
|
Haemophilus b
|
|
|
|
|
|
|
|
Measles, Mumps, Rubella
|
|
|
|
|
|
|
|
Polio
|
|
|
|
|
|
|
|
Varicella, Zoster (chickenpox)
|
|
|
|
|
|
|
Based upon his medical history and physical condition at the time of this examination, the child is free from communicable disease and is in suitable condition to receive child care.
______________________________________ ___________________________________
Print Name of Physician Signature of Physician
______________________________________ ___________________________________
Street Address City State
______________________________________ (_____)___________________________
Zip Code Telephone number
