PIKE CHRISTIAN ACADEMY
Student Application for 2011/12
Paid____ Date____ Date of Application_______
Date of Enrollment_________
Check no. _______ Boy___ Girl___
Grade for 11/12______
Student’s name___________________________
Date of Birth___________
Address__________________________________________________
Is this a change of 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 CURRENT SHOT RECORD, BIRTH
CERTIFICATE, AND SOCIAL SECURITY CARD ON FILE BY THE FIRST DAY OF SCHOOL.
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Student History:
Has the student ever been suspended? _____Expelled? _____Asked to withdraw? _____
If so, please explain on back.
Has the student ever been retained? _____ What grade(s)? _____ Has the student ever
skipped a grade? _____ What grade? _____
Has the student ever been tested for learning disabilities? _____ What were the results?
Please explain on back.
***If the student is entering the fifth grade or above, please have him/her write one
paragraph on a separate page about why he/she wishes to be a student at Pike Christian Academy.
Medical Information:
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
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
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Pike Christian Academy
Permission to transport
Field trips, practices
Each year, we transport our students to New Covenant Church to practice for the Christmas program and graduation/closing ceremonies, etc. Please sign below, giving us permission to transport your child/children for these practices during the 2011-12 school year. 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.
5.
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, etc. I will not hold the school or any school certified driver responsible in the event of an accident.
You are also free to transport your own child to practices.
____________________________Signature of parent(s)/guardian.
____________________________Date
INTERNET USE PERMISSION 2011/12 Permission for Student Internet Use at Pike Christian Academy
__________________________ ______________
Student Name Grade
__________________________ ______________
Student Name Grade
__________________________ ______________
Student Name Grade
__________________________ ______________
Student Name Grade
__________________________ ______________
Student Name Grade
My child(ren) has permission to access the internet at school, under a teacher’s supervision, and according to the rules found in the Student Internet Use Agreement. I understand that violations to these rules may result in my child no longer having access to the internet at school.
____________________________ ___________________________
Parent Signature Date
MEDIA PERMISSION SLIP
2011/12
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
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PCA Latchkey Pick-up list / 11-12
____________________________________________________
Student name(s)
1.Parent name
(mother) ___________(father)____________________
Work phone __________________ ____________________
Cell phone
______________________ _______________________
List all others who might pick up your child:
Name Phone Number
1. _____________________ __________________________
2. _____________________ __________________________
3. _____________________ __________________________
4. _____________________ __________________________
5. _____________________ __________________________
6. _____________________ __________________________
Use only the amount of lines you need. If you need more, add to the bottom
Thank you!
Pike Christian Academy
Parent Agreement – 2011/12
As a parent of a student enrolled in Pike Christian Academy, 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. Any disciplines with which I disagree are mentioned here. ______________________________________
3. I have read and been given a copy of the Tuition and Fees. I have chosen the ____________ payment plan. I agree to pay tuition charges according to the designated schedule. I understand that registration, book fees and the first tuition payment are due and must be paid before my child can enter school.
____I have a second child enrolled, and accept the 10% discount.
____I have a third child enrolled, and accept the free tuition. I understand that I am still responsible for registration and books for the second and/or third child. This discount does not apply to preschool children.
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.
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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: ____________________________________________
Volunteer form for 2011/12
___________________________________________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
400 Clough St.
Waverly, Ohio 45690
Date________________
Your former pupil, _________________________, date of birth _________________,
grade __________________, is now enrolled at our school. Please forward the
following data to the above address:
_____Transcript of High School courses, marks and credits earned
_____High School courses currently being taken and marks to date.
_____Test results (mental ability, reading, achievement, interest,etc.)
_____Copy of health and immunization records
_____Date of last day of attendance
_____Cumulative folder
_____Psychological evaluation
_________________________
Administrator
Student School Record Release Authorization
I hereby authorize ____________________________ to release the information specified above to Pike Christian Academy. I have been advised of my right to review my child’s records. I have also been informed that I have a right to a hearing to contest information contained in these records, and that I may receive a copy of them.
_________________________________
Signature of Parent/Guardian
Student over 18
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PUBLIC SCHOOL TRANSPORTATION WAIVER
Name of Parent or Guardian______________________________
Name of Student ______________________________________
Public School District ___________________________________
County___________________
The _______________________________Board of Education has declared that transportation by school conveyance is impractical for your children. However, the Board will agree to pay the parent or guardian of said pupil in lieu of providing such service. The amount will be calculated by the Ohio Department of Education.
I hereby agree to the above decision of said Board of Education. (if more information is needed, please see the PCA school office personnel).
__________________________ _________________________________________
Date Parent or Guardian signature
I hereby disagree to the above decision of said Board of Education.
__________________________ _________________________________________
Date Parent or Guardian signature
***If you are enrolling more than one student at PCA, please fill out this form for each student.
PIKE CHRISTIAN ACADEMY
Tuition and Fees
Registration Fee: $40.00 - per child, $55.00 - per family
Book Fee: $180.00 - Kindergarten thru 12th grade -
(appreciated if paid at time of registration, see administrator for special circumstances)
Study Island Fee: $10.00 – each year, each student
Tuition for the 2011/12 school year will be $3150.00 for grades K-12. PCA offers a 10% second child discount, with a third child being free. You can choose to accept the discount, pay the full price or you can opt to donate the discounted portion to a program of the school, such as: scholarship, building, improvement, etc. Payments can be made in one of four ways.
Plan #1: Annual - The whole amount of tuition can be paid in one lump sum of $3,150.00 due no later that August 20, 2011.
Plan #2: Semester - Two equal payments of $1575.00 would be due on August 20, 2011
and January 20, 2012.
Plan #3: 10 Months - Payments of $315.00 would be due on the 20th of each month,
August 2011 through May 2012.
Plan #4: 12 Months - Payments of $262.50 would be due on the 20th of each month,
June 2011 through May 2012.
PAYMENT POLICY: All payments are due on the 20th of each month. Late payments
will be subject to a service charge on any unpaid balance. Accounts more than 30 days past due will be brought to the attention of the School Board. If any account becomes 60 days past due, the student will be withdrawn until the account is cleared unless the parents make special arrangements with the Board. Students with outstanding accounts will not be re-admitted(current year or the following year) until the account is clear. Report cards are held by the school at the end of the year until your account is clear.
HOURS OF OPERATION: School begins at 8:20 am and ends at 2:55 pm for K-4 and 3:10pm for 6th – 12th. However, before and after school care is available through our latchkey program. We are open from 6:30 am to 5:30 pm. Latchkey costs $3.00 per day per child, with each additional child being $1 each per day. Children arriving before 8:00 am or remaining after 3:30 pm will be counted present for latchkey. The cost for non-PCA students is $4.00 per day per child. 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 from the latchkey program at Pike Christian Academy.
MEALS: A hot lunch is available daily for $2.00 for Kindergarten through Eleventh grade. Extra milk can be purchased for $0.25.
SNOW DAYS: Child care is available through our preschool program for school age children on days that school is closed but daycare is open (i.e. snow days, Christmas break, etc.) The charge is $20.00 per child per day. On these days, your child will need to pack a nutritious lunch.
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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.
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
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, MP3 players, Ipods, giga pets,
guns or knives, or anything that is determined to be a distraction from learning is allowed on school grounds. Please see our separate policy for cell phones for 6th-12th grades. Cell phones are not allowed under 6th grade.
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).
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Pike Christian Academy
Discipline Policy
The kind and amount of discipline will be determined by the teachers, and if necessary, the Administrator. The discipline will be administered in light of the student’s problem and attitude. All discipline will be based on Biblical principles (eg. Restitution, apologies, swift/painful punishment, restoration of fellowship, no lingering attitudes, etc.) The majority of discipline problems are to be dealt with at the classroom level. In order to maintain consistency, teachers regularly meet together to discuss Biblical standards and school policy concerning discipline. Love and forgiveness will be an integral part of the discipline of a student.
I. Office visits: there are five basic behaviors that will automatically result in discipline from the Administrator (vs. the teacher). Those behaviors are as follows:
; Disrespect shown to any staff member or volunteer. The staff member will be the judge of whether disrespect has been shown.
; Dishonesty in any situation while at school, including lying, cheating and stealing.
; Rebellion, ie. Outright disobedience in response to instructions.
; Fighting, ie. Striking in anger with the intent to harm the other student(s).
; Obscene, vulgar or profane language, as well as taking the Lord’s name in vain.
During the first or second visit with the Administrator, the Administrator will determine the nature of the discipline. The Administrator may require restitution, janitorial work, parental attendance during the school day with the student, writing assignment, paddling, or another measures consistent with appropriate Biblical guidelines. If parents disagree with any of the above mentioned disciplines for their child, they must specify the objection to the Administrator during the application process.
If for any reason a student receives an official office visit (determined by the Administrator), the following accounting will be observed:
ö The first time in any given school year a student is sent to the Administrator for discipline, the student’s parents will be contacted and given the details of the visit. The parents’ assistance and support in averting further problems will be sought.
ö The second office visit in a given school year will be followed by a meeting with the student’s parents and the Administrator.
ö Should a student require a third visit in a given school year, a two-day in-school suspension will be imposed on the student.
ö If a fourth office visit is required in a given school year, the situation will be brought to the School Board to examine the possibility of expulsion.
II. Expulsion: The Pike Christian Academy School Board realizes that expelling a student from school is a very serious matter and should always be carefully dealt with on a case-by-case basis. Forgiveness and restitution are fundamental to our total discipline policy. However, should a student and his/her parents be unable to eliminate behavioral problems before a fourth office visit, expulsion may be the option.
III. Serious Misconduct: Should a student commit an act with such serious consequences that the Administrator deems it necessary, the office-visit process may be by-passed and suspension or expulsion imposed immediately. Examples of such serious misconduct could include: acts endangering the lives of other students or staff members, gross violence, vandalism to the school facilities, violations of civil law, or any act in clear contradiction of scriptural commands. Students may be subject to school discipline for serious misconduct which occurs after school hours.
IV. Readmittance: Should the expelled student desire to be readmitted to Pike Christian Academy at a later date, the School Board, or its delegated committee, will make a decision based on the student’s attitude and circumstances at the time of reapplication.
Pike Christian Academy
Illness Policy
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.
