Preschool Registration Packet 20 2 2 - 202 3 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 Fees Registration Fee (Non - refundable) - $150 per student Tuition : $350 per month for 4 - day program Days: M - TH \ Hours: 8:15 - 12:15pm $280 per month for 3 - day program Days: M - W or M - T - TH \ Hours: 8:15 - 12:15pm Payments are due the third business day of each month Early Drop - in Rate : 7:30 - 8:15 $50 additional per month No Late P ick U p Discounts Pre - Registration Discount : $50 off registration fee if registration is complete before April 1 of the previous academic year Paid in Full Discount : one - month tuition voided if year paid in full prior to first day of school Scholarship Opportunities (Scholarships apply to tuition only, not registration fee) (Scholarships will only be awarded after completed applications are reviewed by the school board) Heritage Scholarship : $25 / month a family member previously attends AJA Community Outreach Scholarship : $25 / month student who documents 25+ hours of volunteer work or community service outside of school ArtWalk Scholarsh ip : win activity at ArtWalk for one - month free tuition * Cannot be used for registration fee and student may use a maximum of one ArtWalk Scholarship per academic year. Sponsorship Submit Tuition Aid Application with completed registration packet. This will be reviewed by finance committee. Preschool Financial Information 2022 - 202 3 Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in blue or black ink) *New Students only Completed Forms Required Instructions ☐ Application Complete front and back side of form – one form per student ☐ Immunization Records Submit Immunization Records for each student ☐ Financial Agreement School Registrar will complete the form to be signed by a parent/guardian ☐ Well Child Visit Complete the one form per student ☐ Topical Medication Permission Form Complete one form per student ☐ Medical Information Complete one form per student ☐ Parent Communication Complete one form per family ☐ Photo Release Complete one form per family ☐ Permission for Student Pickup Complete one form per family ☐ Yearly Asbestos Complete one form per child Registration Checklist 202 2 - 202 3 I. STUDENT LEGAL NAME: LAST FIRST MIDDLE PREFERRED NAME PERMANENT ADDRESS: STREET CITY STATE ZIP DATE OF BIRTH AGE PLACE OF BIRTH (CITY & STATE) SEX MALE FEMALE HOME PHONE STUDENT CELL PHONE SOCIAL SECURITY NUMBER / / CITIZENSHIP USA IF YOU ARE NOT A US CITIZEN, WHAT IS YOUR LEGAL STATUS PERMANENT RESIDENCY VISA (TYPE) RELIGIOUS DENOMINATION ADVENTIST NONE OTHER BAPTIZED YES DATE NO IF SDA, WHICH CHURCH HOLDS YOUR FAMILY MEMBERSHIP HEALTH GOOD FAIR POOR DOES THE STUDENT HAVE ANY PHYSICAL CONDITION THAT WOULD LIMIT HIM/HER IN ANY CAPACITY: YES NO (IF YES, PLEASE DESCRIBE) DOES THE STUDENT HAVE A SPECIAL NEED THAT WOULD HINDER YOU FROM BEING SUCCESSFUL AT AJ A : YES NO (IF YES, PLEASE DESCRIBE) II. FAMILY FATHER’S NAME MAILING ADDRESS CITY STATE ZIP MOTHER’S NAME MAILING ADDRESS CITY STATE ZIP MARITAL STATUS MARRIED DIVORCED OTHER MARITAL STATUS MARRIED DIVORCED OTHER CUSTODIAL PARENT CUSTODIAL PARENT E - MAIL PHONE (HOME) PHONE (CELL) E - MAIL PHONE (HOME) PHONE (CELL) OCCUPATION OCCUPATION EMPLOYER EMPLOYER EMPLOYER PHONE EMPLOYER PHONE (Continued on other side) Application for Admission / Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 500 (Please type or print all information in bl ue or black in k ) Grade Entering III. FINANCIAL PERSON RESPONSIBLE FOR ACCOUNT FATHER MOTHER OTHER (IF OTHER, PLEASE STATE THE PERSON RESPONSIBLE) RESPONSIBLE PERSON’S NAME PHONE MAILING ADDRESS CITY ZIP SOCIAL SECURITY NUMBER / / DO YOU HAVE AN UNPAID ACCOUNT AT ANOTHER SCHOOL? YES NO IF YES, GIVE THE NAME AND ADDRESS OF THE SCHOOL I AGREE TO ASSUME FULL FINANCIAL RESPONSIBILITY FOR EDUCATIONAL EXPENSES AT ABILENE JUNIOR ACADEMY FOR THE ABOVE STUDENT DURING HIS/HER ENROLLMENT. I UNDERSTAND THAT A TRANSCRIPT/DIPLOMA WILL BE RELEASED WHEN THE ACCOUNT IS PAID IN FULL. SIGNATURE OF PERSON RESPONSIBLE FOR ACCOUNT DATE IV. RESPECT STUDENT PLEDGE OF RESPECT: I HEREBY AGREE TO RESPECT AND OBEY THE REGULATIONS AND UPHOLD THE STANDARDS OF ABILENE JUNIOR ACADEMY I WILL DO MY BEST TO MAKE POSITIVE CONTRIBUTIONS TO THE TOTAL SCHOOL PROGRAM. SIGNATURE OF STUDENT DATE PARENT / GUARDIAN PLEDGE OF RESPECT: I HAVE READ THE ANSWERS ON THIS APPLICATION AND FIND THAT THEY ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I AGREE TO RESPECT AND SUPPORT THE REGULATIONS AND POLICIES OF THE SCHOOL AS PUBLISHED OR AMMENDED BY THE ADMINISTRATION AND ENCOURAGE MY CHILD TO DO SO. I FURTHER PLEDGE TO ASSUME THE FINANCIAL RESPONSIBILITY FOR THE STUDENT, AND TO PAY BILLS PROMPTLY OR BE SUBJECT TO LEGAL ACTION. SIGNATURE OF PARENT / GUARDIAN DATE V. CONSENT I UNDERSTAND THAT THIS FORM MAY BE VIEWED BY SCHOOL TEACHERS AND STAFF SIGNATURE OF PARENT / GUARDIAN DATE Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in bl ue or black in k ) I. STUDENT LEGAL NAME: LAST FIRST MIDDLE GRADE RETURNING STUDENT ( Y / N ) APPLICATION FEE EMAIL PHONE PERMANENT ADDRESS: STREET CITY STATE ZIP II. FEES REGISTRATION FEE (DUE AT TIME OF REGISTRATION): GRADE S PreK $ 350 \ $280 (first tuition payment) If paid by April 1 of the previous year .$ 300 TUITION FEE GRADES PreK. $350 per month for 4 - day program = $3500 $280 per month for 3 - day program = $2800 $280 per month for 3 - day program REGISTRATION FEE (NON REIMBURSABLE): $ EARLY DISCOUNT ( Y / N ) T O TA L RE G I STRAT I ON : $ T U I T I ON : $ DISCOUNT: $ TOTAL TUTION ( 10 months): $ II. PAYMENT TUITION MONTHLY PAYMENT: $ OTHER $ NOTE: The monthly payment is due on the third of each month. The final payment is due May 3 rd unless other written agreement has been made. Pledges or third party payments to your account will not be credited until received. You are responsible for the full payment if pledges or third party payments are not received. I , the undersigned responsible party , accept the Financial Agreement. By signing this agreement, I accept full responsibility for payment to our account with Abilene Junior Academy ( AJA ) and understand that my child(ren) will be subject to suspension if payment is not made in full or a written agreement has been submitted and approved by due date each month. Also, I understand that an OFFICIAL TRANSCRIPT will be released only if my account with AJA is Paid in Full. Printed Name Responsible Party Responsible Party Signature Date OFFICE USE ONLY FINANCIAL CLEARANCE: YES NO DATE INITIALS ACCEPT DENY DATE INITIALS FINANCIAL AGREEMENT Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in bl ue or black in k ) Your local Seventh - day Adventist church is committed to assisting families who provide documented need for tuition cost. Please Note: The finance committee needs ALL the information on this form to evaluate your request. Eligibility Requirements: • Application must be turned into the finance committee Children’s names (for whom tuition aid is requested) Age: Age: Age: Age: Grade: Grade: Grade: Grade: Total Tuition Aid Requested per month: $ Family Information Father’s Name: Telephone: Home Address: Street Number City State Zip Code Mother’s Name: Telephone: Home Address: Street Number City State Zip Code Married Separated Divorced Widow(er) Other: OTHER DEPENDENTS (NOT LISTED ABOVE) SHOW NAME AND RELATIONSHIP TUITION AID APPLICATION Personal Income Father’s employer: Gross Monthly Income $ Mother’s employer: Gross Monthly Income $ Other Income Sources Child Support $ _______ Alimony $ _______ AFDC $ _______ Disability $ _______ Unemployment $ _______ SSI $ _______ School Loans $ _______ Scholarships $ _______ VA Benefits $ _______ Conference Aid $ _______ Food Stamps $ _______ Grants $ _______ Investments $ _______ Gifts/Family $ _______ Other: $ _______ Monthly Expenses/Living Costs Rent Own Home Payments made to $ / mo. Address: Street Number City State/Zip Code Telephone: Automobiles Make Make Year Year Payment $ /mo Payment $ /mo Credit Card Payments Credit Card: Credit Card: Credit Card: Payment: $ /mo Amount Owed: $ Payment: $ /mo Amount Owed: $ Payment: $ /mo Amount Owed: $ Other Food $ Tithe/Offering $ Savings $ Utilities $ Child Care $ Auto Repair $ Telephone $ Clothing $ Bank Loan $ Taxes $ Med. Insurance $ Other Loan $ Home Insurance $ Entertainment $ Other: $ Total Expenses/Living Costs per month $ References Name of a relative NOT living with you: Telephone: Name of a friend for the past five years: Telephone: Statement My signature below indicates that: • I request Abilene Junior Academy to consider my application for tuition aid for my child(ren). • I certify that the information I’ve provided on this form is true and correct. • I authorize the finance committee/student aid committee to verify any or all my information. • I authorize the finance committee/student aid committee to verify my payment records, the grades, and/or behavior of my child(ren) being considered for tuition aid. Signature of Father or Guardian Date Signature of Mother or Guardian Date **REMINDER: Submit this completed form and Page 1 of your Federal IRS 1040 Tax Form to Abilene Junior Academy finance committee/student aid committee. Abilene Junior Academy 2545 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in bl ue or black in k ) Parents know who they should go to when their child is sick, however pediatrician visits are just as important for healthy children. Some of the benefits of well - child visits include: • Prevention. Your child gets scheduled immunizations to prevent illness and you can ask your pediatricia n about nutrition and safety in the home and at school. • Tracking growth and development. See how much your child has grown in the time since your last visit and talk with your doctor about your child’s development. You can discuss your child’s milestones , social behaviors and learning. • Raising concerns . Make a list of topics you want to talk about with your child’s pediatrician such development, behavior, sleep, eating or relations with other family members. Present your top three to five questions or c oncerns to the pediatrician at the start of the visit. • Team approach . Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The American Academy of Pediatrics (AAP) supports well - child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child. The American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well child ca re, called Bright Futures, for pediatricians to follow. Each well - child visit has an age - appropriate pre - visit questionnaire The questions focus on developmental milestones, nutrition, safety, your child and family's emotional well - being, and recommendati ons from the AAP. Each visit includes a complete physical exam. At this exam, the health care provider will check the child's growth and development in order to find or prevent problems. The provider will record your child's height, weight, and other imp ortant information. Hearing, vision, and other screening tests will be part of some visits. The American Academy of Pediatrics recommends your child be seen for a well - child check at: 30 months, 3 years and 4 years. My child, __________________________________ has had a well - child check or health screening on ______________________________. This well - child check included a vision, dental and hearing screening. Parent/Guardian Signature _________________________ ________ Date ______________________ Preschool Well Child Visit 2022 - 2023 Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in bl ue or black in k ) Student’s Name ______________________________ I give SVCP staff permission to apply as necessary. (Please initial by each item you give approval for) Sunscreen – for outdoor play Calamine Lotion – for insect bites Aloe Vera – for sunburned skin Triple antibiotic ointment – for superficial wounds Chapstick, Carmex, etc. – for chapped lips Hand and/or body lotion – for dry skin Other, please explain I understand it is my responsibility to provide the items listed above. I also understand it is my responsibility to inform the classroom staff when I bring the(se) item(s) and give the(se) item(s) DIRECTLY to the staff to ensure they are kept out of reach of the children. I hereby release SVCP from all liability for any complications resulting from the administration of the above medication as described. THIS FORM IS FOR TOPICAL MEDICATION ONLY. PLEASE NOTE ANY MEDICATION THAT IS INJESTED FOLLOWS DIFFERENT PROCEDURES. PLEASE SEE THE MEDICATION AUTHORIZATION FORM. Parent / Legal Guardian Dat e Topical Medication Permission Form Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in bl ue or black in k ) STUDENT INFORMATION STUDENT NAME PERMANENT ADDRESS: STREET CITY STATE ZIP DATE OF BIRTH AGE SOCIAL SECURITY NUMBER / / - - FATHER/GUARDIAN MOTHER/GUARDIAN SSN - - PHONE (HOME) PHONE (CELL) PHONE (WORK) - STUDENT’S MEDICAL INFORMATION DOCTOR’S PHONE (OFFICE) PHONE (CELL) DENTIST’S PHONE (OFFICE) PHONE (CELL) HOSPITAL PREFERENCE MEDICAL / HEALTH INSURANCE CO. ID # GROUP # DENTAL INSURANCE CO. ID # GROUP # ALLERGIES TO SUBSTANCES OR MEDICATIONS LIST ANY MEDICATIONS TAKEN ON A REGULAR BASIS MED I CAL H IST O RY Continued on other side Medical Information and Release PARENT/GUARDIAN CONSENT The persons listed below have consented to assume responsibility of my child in case of illness or accident until I can be reached. NAME NAME PHONE (HOME) PHONE (HOME) PHONE (CELL) PHONE (CELL) PHONE (WORK) PHONE (WORK) If emergency services involving medical action or treatment are required and neither parent nor the family physician can be reached for consent, the parents/guardians hereby consent to the rendering of such emergency medical service for the above named student as shall be necessary in the opinion of Abilene Junior Academy or the medical personnel rendering the service. This authorization is given pursuant to the local state Civil Code. I understand that I will be responsible for any medical expenses occurring as a result of such treatment. SIGNATURE OF PARENT / GUARDIAN DATE Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in bl ue or black in k ) Student’s Name Grade Student’s Name Grade Student’s Name Grade Staying informed with what is going on at school is a big part of your child’s success. We want to keep you informed on the events and activities that are happening at A JA as well as communicating with you on a regular basis. Being environmentally conscience, we would like to cut down on postage and paper and communicate with you via email as much as possible. Please check all that apply regarding how you wish for A JA to communicate with you. N ote s sent ho m e w i th student(s) Phone Calls When What Phone Number Email Email address (s) Other Parent Communication Information Parent Communication Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in blue or black ink) Abilene Junior Academy School ( A JA ) makes an effort to promote the positive activities, honors and work of our students in our internal celebrations as well as in our community marketing efforts. We do this using a variety of media formats and publications, including but not limited to brochures, postcards, displays, website and slide shows. An essential component of each of these formats and publications is images of our students. Images have tremendous power to engage online users and readers. Publicizing a student’s work will encourage our students to strive for excellence in his or her schoolwork as well as provide a glimpse of the educational experience at A JA During the course of the school year, there will be times when pictures or videos of your child may be taken that support their education, promote community service or encourage positive behavior. These photos and/or videos include but are not limited to field trips, sporting events, special programs and events, along with normal classroom routines. I understand that any picture or video of a student posted to the website whether individual, group or team will not include personal information. Some of the pictures or videos may be action or candid shots taken during participation in an event while other pictures or videos may be staged for specific purposes. Group shots such as class or team pictures posted to the website may be identified by team or class name, but no individual names will be included. In some cases, the initials of a student might be included in such media so that members of the AJ A family might celebrate the accomplishments of the student’s work. I have been informed that with my permission below, an image of and the work of my child may be used in the various media publications of Abilene Junior Academy School. I understand the conditions under which images and students’ work may be used. Yes - I hereby consent to authorize A JA permission to use my child’s photo, video or class work/art for the purposes mentioned above. I understand and agree that A JA may use these photos, videos and class work/art in subsequent school years unless I revoke this authorization in writing to A JA No - I withhold permission for AJ A to use my child’s photo, video or class work/art for any AJ A media as mentioned above. Student Name (please print) Student Name (please print) Student Name (please print) Parent/Guardian Printed Name Parent/Guardian Signature Date Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in blue or black ink) Abilene Junior Academy requires your consent for your child/children to be picked up from school by anyone other than his/her parents/guardians. This is for the safety of your child/children. No one will be permitted to pick up your child/children if their name is not listed below. All persons must have and show their picture ID. Make sure you list all adults even if you reside in the same household. (parents, grandparents, aunt, uncle, etc.) Student (s) Name(s) Grade Grade Grade Grade Grade I hereby give my consent for the following individuals to pick up my child/children from Abilene Junior Academy: Name Driver’s License State & Number Relationship Parent / Legal Guardian Date Permission for Student Pickup 202 2 - 202 3 Abilene Junior Academy 2542 E. Overland Trl. Abilene, TX 79601 (325)603 - 5000 (Please type or print all information in blue or black ink) Subject : Required notification to parents, teachers, and employees Copies of this dated notification shall be distributed to the organizations of parents, teachers, and employees, or in the absence of such organizations, to the individual parents, teachers, and employees, (per Federal Law 40 CFR 763.93) once each calendar year. This is to be done for every school whether it has asbestos containing products or not. The inspection and management plan for Asbestos - Containing - Building - Materials (ACBM) required by the Federal Asbestos Hazard Emergency Response Act (AHERA) has been performed for this school. The management plan has been submitted to the state for review and approval. A copy is on file at the school office and is available for public inspection upon reasonable notice. If desired, a copy of the plan may be obtained upon payment of a reasonable reproduction cost. *Method of Distribution of This Form: Registration Packet (This form was distributed by one of the following, methods: Mailed, handed directly to parents at registration [not via students], or printed in local paper [attach copy]. The school is to include a completed copy of this dated notification in their asbestos management plan folder.) Name of School : Abilene Junior Academy School Address : 2542 E. Overland Trl. Abilene, TX 79601 County : Taylor Date : You are required to fill in the date. Parent Printed Name: Parent Signature: Yearly Asbestos Notification Form