Enrollment Application

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Shepherd Academy

Email *

Student's Grade Level *

1st

2nd

3rd

4th

5th

6th

7th

8th

Required

Student Name *

Sex *

Male

Female

Address *

Date of Birth *

YYYY

Father's Name *

Phone *

Email *

Address (if different than child's)

Employer *

Church Home

Mother's Name *

Phone *

Address (if different than child's)

Email *

Employer *

Church Home

Person(s) responsible for tuition payments and fees *

Who does the child reside with? (Mark all that apply) *

Father

Mother

Step-Father

Step-Mother

Grandparents

Other

Required

Any current legal documents for this student must be kept on file in the office. It is the sole responsibility of the parent/guardian to provide the school with any updates/changes to these documents. *

Yes

Please list any other children you have enrolled at Shepherd Academy and their grade level. *

Educational Background

Please answer all to the best of your ability.

List all schools, including homeschool, that your child has attended (include grade levels, dates and locations for each response). *

Please explain your reasoning for leaving the last school.

Has the student applicant had any discipline problems or suspension, expulsion from previous schools? If yes, please explain. *

Does the student applicant have any special needs that may affect social development, academic development, or physical abilities? If yes, please explain. *

Has the student applicant ever participated in any additional testing, such as psychiatric, psychological, or educational (Academically Gifted or Exceptional Children)? If yes, please explain and provide documentation of results. *

Has the student applicant been enrolled in academically gifted or exceptional children's programs in previous schools? If yes, please explain. *

Does the student have a current diagnosis? If yes, please list. *

Has the student applicant ever received or is currently receiving any therapy? If yes, please list all current therapies and therapists. *

Please explain why you wish to send your child to Shepherd Academy? *

Please provide the following documentation with this application. Your application will not be processed until all paperwork is completed and all documentation is submitted with the non-refundable application fee. As required by the state of North Carolina all students must complete a physical and maintain up to date immunizations prior to entrance.

1. Birth Certificate

2. Immunization Record

3. Physical documentation completed by physician

4. Most recent achievement test results (3rd-6th grade).

5. Copy of the most recent report card (if applicable)

6. Notarized medical release

I understand that my application will not be processed until this above information is submitted.

I am unable to complete the above request.

Required

Contact and Emergency Information

Please list those who you would like for us to contact in the event of sickness or emergency. These are also the persons allowed to pick up your child from Shepherd Academy. *

It is the sole responsibility of the parent or guardian to notify the school of any changes to the list above. Please check the box to mark your acknowledgement. *

I understand that I am responsible for updating my child's emergency contact/pick up list.

Required

Child's Doctor (include phone number) *

Insurance Provider (if applicable) with policy number

Hospital Preference *

Is your child currently under the care of a doctor? If yes, please explain. *

Does your child take any prescribed medications on a daily basis? If yes, please explain. *

Has your child been previously hospitalized? If yes, please explain. *

Any previous diseases or severe illnesses? If yes, please explain. *

Does your child have any allergies? If yes, please explain. *

Are there any other special instructions or medical information we should know about? If yes, please explain. *

Enrollment Agreement

Below you will find the policies for Shepherd Academy. After reading, please select the acknowledgement.

Please check each box to show you have read each policy. *

Students are expected to show respect to the faculty and staff and to show consideration of others at all times.

The use of illegal or unauthorized drugs on or off campus is prohibited and will lead to expulsion.

Students are not permitted to leave the school campus without permission from proper school authorities.

Shepherd Academy is not responsible for the loss of personal property, whether it occurs by theft, fire, or any other cause.

Shepherd Academy reserves the right of dismissal of any student who persistently and willfully neglects his academic work, demonstrates poor citizenship, reflects adversely on the principles of the school or generally fails to cooperate with instructors or administration.

Students are expected to adhere to the dress code guidelines as described in the student handbook.

Students should consider it a privilege to attend Shepherd Academy, and therefore, do all in their power to maintain the experience and cleanliness of the campus. Any student known to deface or destroy school property will be assessed the full cost of repairs and be subject to possible disciplinary action up to and including expulsion and dismissal.

All students enrolled at Shepherd Academy must maintain a birth certificate, yearly school physical, up to date immunization records, and current legal documents, if applicable, in their cumulative folders. It is the sole responsibility of the parent or guardian to provide the school with any changes or updates to legal documents.

Shepherd Academy admits students of any race, color, nationality or ethnic origin to all rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate in the administration of its education policies, admission policies or other school programs.

A student handbook is furnished to each student. As parents/guardians, and students, we agree to read and adhere to the policies and guidelines set forth in the student handbook.

Any form of fornication or pornography is a violation of the standards of the standards of Shepherd Academy and will lead to expulsion.

As parents/guardians, we agree that Shepherd Academy may use my child's picture in its promotional literature for school use, via print or online.

I agree to the financial policies of Shepherd Academy and I understand that payments for tuition and fees will be made by the dates indicated on the financial agreement form I have signed. My account will be billed a late charge of $25 when payments are more than ten (10) days past due. If my payment is past due more than thirty (30) calendar days my child may be withdrawn from school until my account is in good standing.

As parents/guardians, we are solely responsible for any additional costs associated with school sponsored trips and outings in addition to the monthly or yearly tuition cost.

My child is permitted to take part in all school activities, including sponsored field trips. I pardon the school and church from any liability to me or my child in case of accident or injury to my child while on campus or during any school sponsored outing or field trip.

As parents/guardians, we are responsible for the cost of the administration and materials for the Stanford Achievement test give in 3rd and 6th grade.

As parents, we hereby invest the authorit in the favulty and administration concerning the reasonable discipline of our child as necessary. Furthermore, we agree that we will support the faculty and administration at home as needed.

As parents/guardians, we give our child permission to have access to online educational material. If your child abuses this privilege in any way they may be banned from having online access or expulsion from the school.

I understand that if I or any agent acting in my behalf or on the behalf of my child, bring any illegal action against the school or its agents and such legal action is found in favor of the school or its agents and such legal action is found in favor of the school or its agents, I will be responsible to pay all elgal fees and other expenses related to such action. All disputes shall be settled in binding arbitration.

Required

I understand that by checking the box below, I am agreeing to accept and abide by the rules and standards of Shepherd Academy. *

Yes, I agree.

No, I do not agree.

Required

Send me a copy of my responses.

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