West Valley Christian School How to Enroll Checklist 2013-2014

West Valley Christian School
How to Enroll Checklist
2013-2014
1. Schedule an Informational Visit (Optional)
Campus Tours, Shadow Days and informal interviews are encouraged and available by
calling the Administrative Office at (623) 234-2100.
2. Complete the Application Forms for Admission
All forms listed below must be submitted before processing begins:
 Completed New Student Enrollment Application and returned with a $50 Application Fee. [A $50 non-refundable fee is due with the application and
$150 is due upon acceptance.]
 Notarized Emergency Contact Form
 Financial Commitment Form
 Pastor Recommendation or Parent Written Statement Form
 ADH Emergency Information and Immunization Card
 Private School Affidavit Form
 Birth Certificate (copy)
 Immunization Record (copy)
 Records [If applicable, only one of the following is required]
 Achievement Test Scores & Reports Cards for Last Two Years
 Completed Student Record Transmittal Request
3. Principal Interview
A Principal interview is required prior to acceptance into a West Valley Christian School.
Only students who have submitted all the forms listed above will be scheduled for an
interview. At the time of acceptance, the remaining $150 enrollment fee will be due.
4. Admission Decision
Each family will receive an official letter communicating the admission decision for
your student.
5. Feel Free to Contact the Administration with Questions
Front Office Call (623) 234-2100
Business Office (623) 234-2107
West Valley Christian School
For Office Use Only
Kindergarten—8th Grade
Date Rec’d
Fee Paid
Ck#/Cash/CC
Multi Family
14900 W. Van Buren Street Goodyear, AZ 85338
Phone (623) 234-2100 FAX (623) 234-2199
Enrollment Application
2013-2014
[Complete ALL information and include registration fee with your application.]
STUDENT INFORMATION Please print or type
Student’s Name
Last
First
Middle Name
Address
(
Street Number
Age
City
Date of Birth
Applying for Grade
ZIP
)
Phone
Birthplace
For Term Beginning
Primary Language in Home:
Ethnic Origin:
State
□ English □ Spanish □
Sex:
□
Male
□ Female
Other
□ Caucasian □ Black/African American □ Hispanic/Latino □ Asian/Pacific Islander
□ Native American/American Indian □Multiracial
PARENT (GUARDIAN) INFORMATION
Father/Guardian/Step-Father (circle one)
Mother/Guardian/Step-Mother (circle one)
Last Name
Last Name
First Name
First Name
Street Address
Street Address
City
State
City
Zip
State
E-mail
Zip
E-mail
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Employer
Employer
Occupation
Occupation
Correspondence from the office is sent electronically by email. Please make sure to list your email address.
Please also indicate if this method of communication is not available to you.
□ Please check the box if you do not have regular access to email.
FAMILY INFORMATION
□ Mother & Father □ Mother □ Father □ Mother & Step-Father □ Father & Step-Mother
□ One Parent Deceased □ Other
Relationship
Student lives with:
If parents are divorced or separated, where does student primarily reside?
Who has legal custody?
Name/age/school of other children in family:
1.
Name
Age
School
Name
Age
School
Name
Age
School
Name
Age
School
2.
3.
4.
West Valley Christian School
Kindergarten—8th Grade
14900 W. Van Buren Street Goodyear, AZ 85338
Phone (623) 234-2100 FAX (623) 234-2199
CHURCH / FAITH INFORMATION
Does one Parent/Guardian attend church regularly?
□ Yes □ No
Church Name
Denomination
Pastor’s Name
Church Phone Number
Church Address/City/ZIP
Does student attend the same church as Parent/Guardian?
□
Yes
□
No If no, church name
Is the student open to developing a personal relationship with Jesus Christ?
□
Yes
Does either Parent/Guardian have a personal relationship with Jesus Christ?
□
Yes
Respondent’s Name:
□
No
□
No
Relationship to Student:
ATTITUDE INFORMATION
Please list schools student currently attends or has previously attended:
School Name
Phone Number
Dates
Grades Completed
School Name
Phone Number
Dates
Grades Completed
Has the student ever been suspended? □ Yes □ No Been expelled or asked to withdraw?
If yes, please give full details, including the principal’s name and address of the school.
□ Yes □ No
ACADEMIC INFORMATION
Has the student ever failed a grade?
□ Yes □ No
If so, please state grade and date
Reason:
Does the student have a learning disability?
□ Yes □
No
Has the student been in a resource classroom for educational support?
□ Yes □ No
Does the student have an IEP (Individualized Education Plan), a 504 Plan or received special accommodations?
□
Yes
□ No
If yes, attach a copy.
Please rate the student’s interest in attending WVCS? (circle one) 0=none 10=very interested 0 1 2 3 4 5 6 7 8 9 10
West Valley Christian School
Kindergarten—8th Grade
14900 W. Van Buren Street Goodyear, AZ 85338
Phone (623) 234-2100 FAX (623) 234-2199
USE OF PICTURES CONSENT
Many pictures are taken at West Valley Christian School during the year of individual students and various groups for use
on our website and in various promotional materials. By enrolling your student at West Valley Christian School you give
the school permission to use pictures of your student. If you do not wish to have your student’s picture used, you must
notify the school office in writing.
STUDENT STATEMENT (required of 5th - 8th grade students only)
By signing this application, I am indicating that I fully understand the rules of behavior as outlined in the “Student/Parent
Handbook” (located online at www.wvchristianschool.org) and that these rules apply for the entire year, on and off the
West Valley Christian School Campus. I further understand that the rules and regulations are subject to revision by the
school at any time, and that each student/family is expected to be familiar with current school rules. I agree to abide by
the rules and regulations of the school. I also realize that if I break the rules, my continued enrollment will be subject to
immediate review.
Student Signature
Date
PARENT/GUARDIAN STATEMENT
I/We understand and agree that West Valley Christian School a is private evangelical Christian school where enrollment is
a privilege and not a right. I/We certify by signature below that I/we understand the general rules and regulations that are
published in the “Student/Parent Handbook” (located online at www.wvchristianschool.org). I/We further understand
that the rules and regulations are subject to revision by the school at any time, and that each student/family is expected to
be familiar with current school rules. I/We agree to abide by the rules and regulations. In the role as parent and/or
guardian, I/we promise to enforce these rules. I/We understand and agree that violations of any West Valley Christian
rules and regulations will be dealt with by the school administration and may result in expulsion from West Valley Christian School. In addition, I/we agree to accept full responsibility for all obligations that may result from injury incurred by
my student as a result of participation in any school-sponsored activity. If I/we cannot be contacted in an emergency, call
the physician listed on the Notarized Emergency form and follow his/her instructions. If the school cannot contact anyone
listed, the school is authorized to act in whatever manner is deemed appropriate by school personnel. I/We also agree to
comply fully with the financial requirement of the school regarding payment of tuition and understand and agree that the
student may be removed from the school if tuition payments become delinquent.
Parent/Guardian Signature__________________________________________ Date____________________
Parent/Guardian Signature__________________________________________ Date____________________
West Valley Christian School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs and
activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national
and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and
other school-administered programs.
West Valley Christian School
Kindergarten—8th Grade
14900 W. Van Buren Street Goodyear, AZ 85338
Phone (623) 234-2100 FAX (623) 234-2199
EMERGENCY CONTACT & HEALTH INFORMATION FOR 2013-14
STUDENT INFORMATION
Student
Grade
Student Address
Home Phone (
Date
City
)
Zip Code
Birthdate
FAMILY INFORMATION
Father/Step Father/Guardian
E-mail
Home Phone
Work Phone
Cell Phone
Mother/Step Mother/Guardian
E-mail
Home Phone
Work Phone
Cell Phone
EMERGENCY CONTACT INFORMATION
Please list two or three people who can assume temporary care of your student if you cannot be reached:
DO NOT LIST PARENT/ GUARDIAN!
1. Name
Relationship
Daytime Phone
Cell
2. Name
Home
Work
(Circle One)
Work
(Circle One)
Work
(Circle One)
Relationship
Daytime Phone
Cell
3. Name
Home
Relationship
Daytime Phone
Cell
Home
List any individual(s) who SHOULD NOT pick up and/or have contact with your student:
1.
2.
EMERGENCY & HEALTH INFORMATION
In case of serious accident or illness at school, your student will be sent to an emergency medical facility. The parent/guardian
is responsible for all expenses.
Physician
Phone
Known Allergies
Daily Medications
(Please list any medicine taken at home and at school)
Other Pertinent Medical Data
It is the policy of West Valley Christian School to require that all students be covered
by a health insurance policy.
Name of Family Health Insurance
West Valley Christian School
Permission for any School Related Function and
Consent for Medical Treatment
2013 - 2014
Must be signed in presence of Notary Public.
STUDENT NAME
GRADE
DATE
The undersigned hereby gives permission for the above named student to attend any school-related function for the period
from August 1, 2013 to June 1, 2014 . In the event there is any emergency involving him/her, permission is hereby granted for
West Valley Christian School personnel to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of
any physician or surgeon or dentist licensed to practice in any state, and school personnel shall not be held personally liable.
If emergency service involving medical action or treatment is required, and neither the parent nor guardian can be contacted,
the undersigned herewith consents for the student named above to be given medical care by a doctor selected by the school.
Any intentional omission or falsification of this form may subject the parent/guardian to full liability for any subsequent injury, or may cause the student to be removed from sports participation.
The parent/guardian must complete a written authorization form provided by the school for prescription medications that will
be taken at school. All prescription medications must be turned in to the school office in the container dispensed by the pharmacy.
Known Drug Allergies: _______________________________
Signature of Parent or Legal Guardian
(Must Sign in Presence of Notary Public)
None
State of Arizona, County of Maricopa
Subscribed and sworn to before me
This
day of
,
Notary Public
Signature
My Commission Expires
14900 W. Van Buren Street Goodyear, AZ 85338
(623)234-2100 Fax (623)234-2199
www.wvchristianschool.org
West Valley Christian School
Kindergarten—8th Grade
14900 W. Van Buren Street Goodyear, AZ 85338
Phone (623) 234-2100 FAX (623) 234-2199
2013 - 2014
Pastor Recommendation or Parent/Guardian Written Statement
Note: Parent/Guardian Written Statement (on page 2) may be used in place of Pastor’s Recommendation
Family Information
Family Name
Family Address
Telephone
E-mail
Pastor Recommendation
applicant full name
grade
has applied for admission to West Valley Christian School.
We would welcome any comments or insights you have regarding his/her character and spiritual life. We
have found a pastor’s perspective quite valuable in getting to know an applicant better and helping us to
determine if West Valley Christian School is an appropriate placement. Thank you for your cooperation.
In what capacity and for how long have you known the applicant?
Please comment on the applicant’s involvement in your church or congregation.
On average, how many times during a month does this applicant participate in church or congregationally related services or activities?
In what congregationally related activities is this applicant typically involved?
What involvement, if any, have you observed on the part of this applicant’s parent(s) or guardian with your
church or congregation?
Please share with us any specific concerns or highlights you have on the character of this applicant.
Do you recommend the family for admission to West Valley Christian School?
□
Enthusiastically
□ Yes
□ Yes, with reservation
□ No
Pastor / Church Leader Name
Church Name
Phone Number
Pastor’s E-mail
Address
City
State
Zip Code
Note: Although rarely requested, a parent/guardian has the legal right to view their student’s file. If you wish this information to remain confidential, please indicate by checking the box.
□
Please return this form directly to the family or mail/fax to
WVCS Attn. Admissions, 14900 W. Van Buren Street Goodyear, AZ 85015 (623)234-2100 Fax (623)234-2199
West Valley Christian School
Kindergarten—8th Grade
14900 W. Van Buren Street Goodyear, AZ 85338
Phone (623) 234-2100 FAX (623) 234-2199
Parent/Guardian Written Statement 2013 - 2014
Student’s Full Name
Date
While the Pastor’s Recommendation (see page 1) is very helpful, parents/guardians may submit
this Written Statement in place of the Pastor’s Recommendation. In your statement, please include
the following: 1) discuss any spiritual goals you might have for your child; 2) comment on your
desire for your child to receive a formal education that is based on Christian values as found in the
Bible and reflected in the life and teachings of Jesus Christ. Please feel free to use additional
sheets of paper as necessary.
Parent Signature
14900 W. Van Buren Street Goodyear, AZ 85338 (623)234-2100 Fax (623)234-2199
www.wvchristianschool.org
West Valley Christian School
ENROLLMENT FINANCIAL FORM
2013 – 2014
Parent Name
Phone
Person responsible for tuition and fees (if different from above)
Address
City
State
Zip
RETURNING STUDENTS
YES, I do want to re-enroll my child(ren) at West Valley Christian School for the upcoming school year. I
understand that the re-enrollment fee is due with the re-enrollment packet. Re-enrollment fees reserve
space in the classroom and are non-refundable. The re-enrollment fees are per student as follows;
$75 February 1st - February 28th
$100 March 1st – March 30th
$150 After March 30th
NEW STUDENTS
YES, I do want to enroll my child(ren) at West Valley Christian School for the upcoming school year. The
enrollment fee is $200 with $50 due with the application and the remaining $150 due at the time of acceptance. (The $50 enrollment fee is non-refundable.)
Monthly Payment Plans (Please choose a monthly payment plan and a payment option)
□
□
□
12 Monthly Payments (July 1, 2013 – June 1, 2014)
11 Monthly Payments (August 1, 2013 – June 1, 2014)
10 Monthly Payments (August 1, 2013– May 1, 2014)
Monthly Payment Options
Monthly payments can be made through the front office. WVCS accepts all major credit cards in addition to
cash, checks and money orders. Parents are encouraged to use bill pay through their bank if this option is
available. A $15.00 late fee will be added to any payment not received by West Valley Christian School by the
15th of the month.
Signature of Person Financially Responsible
Returning Student(s) Name(s)
New Student(s) Name(s)
Date
Fall Grade
Fall Grade
*** For tuition and fees, please refer to the enclosed 2013 - 2014 Tuition/Fee Schedule. ***
Please direct any questions concerning tuition/fees to the Business Office: (602) 234-2107
West Valley Christian School
Kindergarten—8th Grade
14900 W. Van Buren Street Goodyear, AZ 85338
Phone (623) 234-2100 FAX (623) 234-2199
STUDENT RECORD TRANSMITTAL REQUEST
Under PL 93-380, Sec 438 (Protection of the Right and Privacy of Parents and Students), student
records cannot be released without the signed consent of the parent, guardian, or student (if over
18 years of age).
___________________________ (name of former school)
has my permission to release the school records for
the students listed below.
Student’s Name
Date of Birth
Grade
___________________________
___________
______
___________________________
___________
______
___________________________
___________
______
___________________________
___________
______
Withdrawal Date___________________
Signature of Parent/Guardian___________________________ Date
Address and phone number of former school:
_______________________________________
(Street Address)
_______________________________________
(City)
(State)
(Zip)
_______________________________________
(Phone Number)
_______________________________________
(Fax Number)
www.wvchristianschool.org
_______________
CDC/SGH# or name:____________________
Arizona Department of Health Services
Bureau of Child Care Licensing
Emergency, Information and Immunization Record Card
Child’s Name:
Updated:
Date Enrolled:
Home Address (#, Street, City, State, Zip Code):
Date Disenrolled:
Date of Birth:
Home Phone:
Sex:
Mother or Guardian Name:
Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional):
Contact Telephone Number:
Father or Guardian Name:
Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional):
Contact Telephone Number:
male
female
I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
If Medical care is necessary, call:
Contact Telephone Number:
Health Care Name:
Provider*
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her
health and safety. It is understood by me that the expense of this service will be accepted by me.
In case of injury or sudden illness, I request that this individual be called first:
Does your child have insurance coverage?
No
Yes
Name of Insurance Company:
The following individual(s) may NOT remove my child from the facility:
Name(s):
Custody papers have been provided and are on file at the facility.
Telephone Authorization Code (optional):___
yes
_______
no
Immunization Information
(A licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and
Immunization Record card.)
For information regarding current immunization requirements go to:
www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630.
One of these items must accompany the EIIR card at all times:
Copy of current official documented immunization record attached
Religious Beliefs exemption form signed by parent/guardian attached
Medical Exemption form signed by physician and parent/guardian attached
Signed Laboratory Proof of Immunity form attached
Notification of immunizations needed sent to Parent(s) or Guardian(s):
Updated immunizations received and attached:
mo /day/ yr
mo /day/ yr
mo /day /yr
mo /day/ yr
mo /day/ yr
mo /day /yr
Medical Information
No
Yes
Is child usually susceptible to infections and if so, what precautions need to be taken?
If yes, list precautions:
No
Yes
Is child subject to convulsions and what should be our procedure if one occurs?
If yes, specify procedure:
No
Yes
Is there any physical condition that we should be aware of and what precautions should
be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?
If yes, list precautions:
No
Yes
Is child allergic to food or other substances?
If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:
Additional comments:
Other special instructions:
This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by:
Parent/Guardian PRINTED Name:
SIGNED Name:
G:\Forms\Emergency Information and Immunization Record Card (9/11)
DATE:
PRIVATE SCHOOL AFFIDAVIT OF INTENT
Dr. Donald D. Covey – Maricopa County Superintendent of Schools
Maricopa County Education Service Agency
STUDENT INFORMATION:
NAME: ____________________________________________________________________ DATE OF BIRTH: ___________________________
(LAST, FIRST, MIDDLE)
SCHOOL DISTRICT OF RESIDENCE: __________________________________
PARENT/GUARDIAN INFORMATION:
NAME: ___________________________________________________________________ TELEPHONE NUMBER: _______________________________
(LAST, FIRST, MIDDLE)
HOME ADDRESS: _________________________________________________________ CITY: _________________________ ZIP: _________________
PRIVATE SCHOOL INFORMATION:
PRIVATE SCHOOL NAME: ___________________________________________________________________________________
ADDRESS OF SCHOOL: _______________________________________________CITY:_______________________________ ZIP: ________________
ARIZONA STATE PRIVATE SCHOOL LAWS FOR REGISTRATION AS PRESCRIBED BY THE ARIZONA REVISED STATUTES:
15-802 A: Every child between the ages of six and sixteen years shall attend a school and shall be provided instruction in at least the subjects of reading, grammar, mathematics,
social studies and science. The person who has custody of the child shall choose a public, private or charter school or a homeschool as defined in this section to provide instruction.
2. If the child will attend a private school or homeschool, file an affidavit of intent with the county school superintendent stating that the child is attending a regularly organized private
school or is being provided with instruction in a homeschool. The affidavit of intent shall include:
(a) The child's name.
(b) The child's date of birth.
(c) The current address of the school the child is attending.
(d) The names, telephone numbers and addresses of the persons who currently have custody of the child.
AUTHORIZATION:
PARENT/GUARDIAN SIGNATURE: __________________________________________________
Subscribed and sworn (or affirmed) before me this:
STATE OF: _________________________
______ day of________________, 20__________.
COUNTY OF: _______________________
NOTARY SIGNATURE: _________________________________________________________________
Submit this form either by mail or in person to the Private School Services Division at the address listed on the bottom of this page .
4041 N. Central Avenue, Ste. 1100, Phoenix AZ 85012 • Phone 602-506-3866 • Fax 602-506-3753
Homeschool Hotline 602-506-3144
www.maricopa.gov/schools
Known as experts. Renowned for service.