Preschool Registration Form 2017-18

Name of person completing this form: *

Email: *

Student Legal Name *

First Name Last Name

Name Student Uses

Student Local Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Student Gender *

Male Female

Student Date of Birth *

Month Day Year

Previous School Child Attended *

Student Ethnic Origin (Must check Yes or No) *

Yes, Hispanic or Latino (a person of Cuban, Mexican, or Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) No, not Hispanic or Latino

Student Race (must check at least one box-check all that apply) *

American Indian or Alaskan Native- I (origins in any of the original peoples of North or South America including Central America and who maintains tribal affiliation or community attachment) Asian- A (origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent e.g. Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam) Black or African American- B (origins in any of the black racial groups of Africa) Native Hawaiian or Other Pacific Islander –H (origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands) White–W (origins in any of the original peoples of Europe, Middle East, or North Africa)

Student Country of Birth:

Church you regularly attend:

Student’s Primary Language:

Parent’s Primary Language:

Student Legal Custody (Check all that apply) *

Both Parents Mother Father Grandparent Foster Parent Aunt / Uncle

Select Campus *

Downtown - West Palm Beach (Infants through Pre-K4/VPK) Palm Beach Gardens (2's - Pre-K4/VPK)

Select Downtown Progam *

Infant Toddler 2's 3's Pre-K VPK

Select Gardens Progam *

2's 3's Pre-K VPK

Select Infants and Toddlers Schedule *

2 Day (T, Th) 9:00 -3:00 3 Day (M,W, F) 9:00 -3:00 3 Day (M, W, F) 7:30-6:00 5 Day (M-F) 9:00-3:00 5 Day (M-F) 7:30 – 6:00

Select 2’s, 3’s, Pre-K4 Schedule: *

2 Day (T,Th) 9am-3pm 3 Day (M,W,F) 9am-3pm 3 Day ( M,W,F) 7:30am-3pm 3 Day (M,W,F) 7:30am-6pm 5 Day (M-F) 9am-3pm 5 Day (M-F) 7:30am-3pm 5 Day (M-F) 7:30am-6pm

VPK Schedule (must be 4 by September 1st) *

VPK Only voucher (M-F) 9:00 – 12:00 VPK with voucher (M-F) 9:00 – 3:00 VPK with voucher (M-F) 7:30 – 3:00 VPK with voucher (M-F) 7:30 – 6:00

Allergy Information

Medication Food Plant Latex Insect Other

Please list allergies:

*If your child requires an Epi Pen or Allergy it must be given to the office with a prescription*

Any other information (child wears glasses, has braces, etc.)

Mother or Guardian

Home Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Can you receive text messages on cell phone?

Yes No

Address ( if not the same as student)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail

Place of Employment

Father or Guardian

Home Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Can you receive text messages on cell phone?

Yes No

Address ( if not the same as student)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail

Place of Employment

Siblings

	Name	Age	Grade	School Sibling Currently Attends
Sibling #1
Sibling #2
Sibling #3
Sibling #4

Emergency Contact

	Name	Phone	Relationship to Student
Contact #1
Contact #2
Contact #3

*Important, Everyone Must Answer Questions A-D Below*

A. Is there a Court Order barring either parent from removing the student from school? *

No Yes

If yes, the school must be provided with a copy of the applicable Court Order.

B. Do parents have shared (or joint) parental rights and responsibility?

No Yes

If no, provide the school with a copy of the Court Order which limits either parent’s parental rights or responsibilities regarding the student.

C. Does each individual parent have the ability to make a final decision regarding educational decisions for the student?

No Yes

If no, provide the school with a copy of the Court Order stating that one parent has final parental decision making authority regarding education.

D. Is there a Temporary Restraining Order, Permanent Restraining Order, Order of No Contact, or other Court Order that restricts or impacts access to the students by anyone, including a parent?

No Yes

If yes, the school must be provided with a copy of the applicable Court Order.

I hereby give permission for the school to use my child’s photograph, video image, writing, voice recording, name, grade level, programs, playbills, school productions, web sites, etc. and/or similar school sponsored publications or in school approved news media interviews, releases, articles, and photographs. I also provide permission by the school to the media and governmental entities of my child’s name grade, school name, and honors my child has received for public announcement of recognition of my student’s accomplishments. I understand that if no box is checked I am giving my permission for my child’s name and photograph to be included in any publications or presentations. *

I give permission I do not give permission

ARTICLE XV, B, 9, a, PBC Rules requires that parents must receive a copy of the Child Care Facility Brochure, KNOW YOUR CHILD'S DAY CARE CENTER. I have received a copy of the Child Care Facility Brochure, KNOW YOUR CHILD'S DAY CARE CENTER.

ARTICLE IX, C, 6, PBC Rules requires that parents be notified in writing of the disciplinary practices used by the childcare facility. I have received in writing the disciplinary practices used by this childcare facility as stated in the Parent/Center Agreement.

By entering the child's name in the box below you are giving permission for your child to attend functions, with his/her class, in areas on First Baptist Church property other than the first floor of PBCA (i.e., Chapel services, Gymnastics, Music, Gymnasium, etc.). I understand that he/she will not be leaving the grounds of the First Baptist Church. *

TUITION PAYMENT

Person responsible for payment other than parent.

Relationship to Student

Address

Phone Number

Area Code Phone Number

Please check one payment plan for tuition: *

Payment Option 1 (Annual payment due on or before August 1, 2017) Payment Option 2 (12 equal payments due on the 1st of each month, August 1, 2017 – July 1, 2018

I have read and understand my financial obligations as set forth on the Financial Information Sheet. *

I understand I need further clarification

Mission Statement

We exist to form a partnership with parents to provide a strong spiritual foundation for their children in a loving, nurturing, Christ-centered environment of discovery and learning.

Philosophy

Palm Beach Christian Academy (PBCA) is a ministry of the First Baptist Church of West Palm Beach. We share a common philosophy based upon an understanding of the needs of children. As children pass through stages of development, which occur in a predictable sequence, we believe it is our responsibility to recognize these stages and to plan experiences that will nurture and facilitate maximum growth. These experiences are designed to meet the needs of the total child, thoroughly promoting intellectual, social, emotional, physical and spiritual growth.

Statement of Faith

We believe in the unity and equality of the Trinity: God the Father, God the Son, and God the Holy Spirit (1 John 5:7-8).
We believe that salvation is by grace through faith, not of works (good deeds, baptism, giving money, etc.) (Galatians 2:16).
We believe in the deity of our Lord Jesus Christ, in His virgin birth, in His sinless life, in His miracles, in His vicarious and atoning death through His shed blood, in His bodily resurrection, in His ascension to the right hand of the Father, and in His personal return (John 3:16).
We believe that the Bible, both the Old and New Testaments, was inspired by God, is inerrant and is our only rule in matters of faith and practice. (II Timothy 3:16)

Values

To teach that the Bible is the inspired and the only inerrant and infallible authoritative Word of God, thus developing attitudes of love and respect toward it (II Timothy 3:15-17, II Peter 1:20-21).
To encourage the student to develop self-discipline and responsibility from God’s perspective (I Timothy 4:7, I Corinthians 9:24-27).
To teach the student to treat everyone with love and respect as unique individuals created in God’s image (Philippians 2:1-4, Ephesians 5:21).
To teach the student how to become a contributing member of his society by realizing his need to serve others (Galatians 5:13, Romans 2:10).
To teach the student to understand and use fundamental processes in communicating and dealing with others (such as reading, writing, speaking, listening, and mathematics) (II Corinthians 5:20).
To teach and encourage the student to use good study skills and habits (II Timothy 2:3-7).
To teach the students creative and critical thinking based upon the proper use of biblical criteria for evaluation (II Timothy 3:14-17).
To teach the student biblical skills for personal and social relationships (Psalm 119:9, Ephesians 4:12).
To teach each student to develop a personal relationship with God (Philippians 3:10, 4:7).
To teach the student an understanding of and an appreciation for God’s world, developing an awareness of man’s role in his environment and his God given responsibility to subdue, use and preserve it properly (Psalm 8:6, Hebrew 2:6-8).

Sanctity of Human Life

Palm Beach Christian Academy believes in the sanctity of human life. PBCA believes that all human life is sacred and created by God in His image. Human life is of inestimable worth in all its dimensions, including pre-born babies, the aged, the physically or mentally challenged, and every other stage or condition from conception through natural death. We are therefore called to defend, protect, and value human life.

Statement of Final Authority

We believe that the Bible is the absolute Truth and God’s final authority. We believe both the Old and New Testament is the inerrant, verbally inspired, and infallible Word of God.

Gender, Marriage, and Sexuality

Palm Beach Christian Academy believes that God created human beings in his image in two sexual kinds- male and female (Gen. 1:26-27). Gender is a part of God’s good creation, a revealed biological reality, identifiable at birth, and evident in the course of everyday life in expressions of masculinity and femininity.

God designed men and women to unite in marriage, which is complementary (involving one of each sexual gender), comprehensive (involving all of life, including physical sexual union), exclusive (monogamous and faithful), permanent (until separated by death), and generative union (designed for the oriented toward the bearing and rearing of children) (Gen. 2:18-25). Through this union, a husband and wife picture for humanity the relationship between Christ and his church (Eph. 5:22-23).

A Part of God’s benevolent design, marriage is basic to human flourishing and arises in cultures across history from realities that are discernable in creation (Ro. 1:18-27): the anthropological reality that men and women are different and complementary; the biological reality that they unite to create new life; the sociological reality that children deserve to be with the mother and father that created them. Only men and women can unite in marriage since only a man and a woman can unite in a way that honors the nature of human sexuality.

Sexual intimacy is the exclusive privilege and responsibility of a husband and wife (I Cor. 6:18; 7:2-5; Heb. 13:14). Because of Adam’s sin, every human being is born sexually perverted, creatively and destructively seeking sexual fulfillment in ways that ignore The Creator, reject his design, and distort his intent. Any form of sexual immorality (including adultery, fornication, homosexual behavior, incest, and use of pornography) is sinful and offensive to God (Matt. 15:18-20; I Cor. 6:9-10).

While all people are sexual sinners, God offers redemption to all who confess and repent of their sin, seeking His mercy for forgiveness through Jesus Christ. By means of God’s Spirit, his Word, in the context of the church, real transformation is possible for sexual sinners of every kind, even if final glorification awaits us in the new creation.

All persons- regardless of what they may believe or practice- are worthy of kindness, dignity, and respect because they are made in the image of God. Love for God and people require that Christians speak about these things and that they do so in a manner consistent with the compassion and conviction of the Lord Jesus Christ.

Code of Christian Conduct

Palm Beach Christian Academy has the right to discipline or ask a student to withdraw for any reason, but failure to comply with the following standards of conduct will subject the student to potential disciplinary action, up to and including expulsion or dismissal.

Students at Palm Beach Christian Academy are expected to adhere to the Code of Christian Conduct, which includes but is not limited to:

dressing in conformance with one’s biological sex as identified at birth
using the restrooms, locker rooms, and changing facilities conforming with one’s biological sex as identified at birth
abstaining from all intimate sexual conduct outside the marital union of one man and one woman
refraining from stealing or cheating
abstaining from verbally or physically harming another person

Parent/ Guardian Agreement

I understand the principles outlined in the PBCA Christian Philosophy. I agree that it is imperative for parents and school to act in unity, and I will support the values and statements adopted by First Baptist Church of West Palm Beach (PBCA) with my children, both inside and outside of the school environment. *

I agree I need further clarification

While Palm Beach Christian Academy does not require families or students to espouse the Christian faith, applicants should be aware that the teaching of biblical doctrines and principles permeates every aspect of a PBCA education. Questions and discussions are always welcome inside and outside the classroom. However, applicants who are antagonistic toward Christian beliefs will be better served by selecting another school. *

I agree I need further clarification

I agree to read and abide by all conditions as defined in the Parent/Center Agreement; and I understand that the Parent/Center Agreement may be terminated by the Parent and/or Guardian, or PBCA upon notification of intention at least two (2) weeks in advance, or at any time by mutual agreement of both parties. *

Yes No

I agree that in the event I voluntarily withdraw my child from PBCA, or in the event I am asked to withdraw my child for violation of one or more of the codes of conduct that I am not entitled to a refund of any kind for the month in which the decision is made. *

Yes No

I agree to read and abide by all conditions as defined by the Sick Policy located in the Parent/Center Agreement. In summary, children who show signs of illness within the previous twenty-four hours cannot be accepted in the preschool room. *

Yes No

I agree that any claim, controversy or dispute arising from or related to this Agreement, including, but not limited to, any claim between the PBCA, Undersigned and/or Student, for any breach of contract, personal injury or property damage, shall be settled first by submission to non-binding mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, a division of Peacemaker Ministries. Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction. The parties understand that these methods shall be the sole remedy for any controversy or claim between the parties and expressly waive their right to file a lawsuit in any civil court against one another for such disputes, except to enforce and arbitration decision or award. *

Yes No

Has the student ever been evaluated or referred for evaluation for learning difficulties or school adjustment problems by a school official, psychologist or other professional? *

Yes No

If yes, please explain or attach a copy of the evaluation. (Note: All evaluations, diagnosis, IEP, 504, etc. must be submitted prior to student acceptance into PBCA.)

Computer Use Policy

PBCA offers computers to our students to serve as a resource for enriching curriculum and learning objectives. Computers will be used for legitimate assignments or activities as prescribed by administrators, faculty, or staff. Students may not use computers without permission, share passwords, use obscene or inappropriate language, threaten our network or its integrity, download, install, or copy program files to the network without the network administrator’s permission, search for, send, or receive messages that are deemed offensive by PBCA Administration, unlawfully copy, save, or redistribute copyrighted material (users should assume material is copyrighted unless noted), subscribe to any services or order any goods or services, share their home address, phone number or other information over the internet, visit social network sites and/or maintain a social network site, be careless or wasteful with computer resources such as paper, ink, etc.

Students of PBCA may not be involved in any way with cyber bullying, hacking, harassment, misrepresentation, plagiarism, or indecent material while using any computers on campus. Violation of this policy may result in the loss of computer privileges, failure in the appropriate class, or possible suspension or expulsion from school. Faculty members have the right to interrupt computer usage at any time. Administration has the right to interrupt and take appropriate action regarding inappropriate computer use on campus. *

I understand I need further clarification

School Health Service Consent

I hereby give my consent for this child to participate in the Health Service Program. This means my child will receive first-aid and emergency care in school if needed.In case of an accident or illness where treatment is not needed, but where my child is unable to remain at school (refer to PBCA sick policy), I request the school to contact parent/guardians first. In the event that PBCA is unable to reach parents/guardians, emergency contacts will be called for care until parent/guardian can be reached.

I give my consent I do not give my consent

If consent is not given please explain

All-School Medical Emergency/Permission to Transport Statement

I do hereby state that I am the parent or guardian of the child named on this form. In order to expedite care of this child, I hereby give my permission for responding emergency team to immediately initiate treatment and transport of my child to the preferred or appropriate medical facility according to what they deem is indicated by the nature or extent of the injuries. I agree to be financially responsible for my child’s treatment and transport, and I will notify in writing any changes to this information. *

I give my consent I do not give my consent

If consent is not given please explain

Permission to Treat Statement

I (fill in your full name and address)

County:

am the parent/guardian of

a minor, age

born (DOB)

Month Day Year

who resides with me at the address set forth above. In case of an emergency, I authorize any representatives of PBCA, in whose care the minor has been entrusted, to present such minor to an approved medical treatment center, and do consent to an x-ray examination, anesthetic, medical, or surgical diagnosis or treatment, and hospital care, to be rendered to the minor under the general practitioner or surgeon licensed to practice medicine in the United States of America. I agree to be financially responsible for my child’s treatment. I also request that I will be notified of my child’s condition and admission as soon as possible.

Insurance Information

Insurance Co. covering child:

Policy #

Exp. Date

Month Day Year

Physician

Phone Number

Area Code Phone Number

Physician's Address

Beginning of School Year Attendance

Space is limited at our school and waiting lists form quickly. If you anticipate that your child will be absent during the first week of school, we ask that you notify the office before the new school year begins. Any student who does not attend school during the first week and neglects to notify the school will risk losing their position in the class. *

I understand I need further clarification

By signing below, I acknowledge that I have read and understood the 2014-2015 PBCA Registration Form and Parent Handbook in its entirety and under penalties of perjury, I declare that the facts stated on this form are true and accurate. Florida Statutes Sec. 95.525 (3) provides that whoever knowingly makes a false declaration under penalties of perjury is guilty of a felony of the third degree. *

Date: *

THIS FORM MUST BE NOTARIZED

All notarized forms need to be signed in front of a notary. PBCA provides a notary, please do not sign form prior to visiting notary. You may also bring form notarized from another notary.

Sworn to and subscribed before me this _____day of ________________, 20_____ , by

________________________________ who is personally known to me or has produced the following

identification_____________________________________________

Notary:_________________________________________

___________________________________________ ______________________________
Signature of School Administrator Date

Preschool Registration & Acknowledgement Form