Application for Admission

Heritage Christian School

5412 67th Ave. W., University Place WA 98467

Phone: (253) 564-6276 Fax: (253) 460-1695 Web: www.heritagecs.net

Date:______For School Year: 20_____ to 20______Entering Grade: ______

1. Applicant’s Full Name:______Nickname:______

Address:______City:______State:______Zip:______

Home Phone:______Date of Birth:______/______/______

Student lives with (check all that applies): __Father __Mother __Stepfather __Stepmother __Guardian

Name and age of siblings:______

Has student ever been issued an IEP? _____Y _____N Has student ever been issued a 504? _____Y _____N

2. Residential/Custodial Parents. Please separately list parents/guardians that applicant lives with:

Name:______Relation to student:______

Address:______City:______

State:______Zip:______Home Phone:______Cell/Pager:______

E-mail: ______@______.______

Employer:______Work Phone:______

Name:______Relation to student:______

Address:______City:______

State:______Zip:______Home Phone:______Cell/Pager:______

Employer:______Work Phone:______

3. Shared Custody. Please list other parent(s) who share custody of applicant:

Name:______Relation to student:______

Address:______City:______

State:______Zip:______Home Phone:______Work Phone:______

Has custody when?:______

4. Name of church:______Pastor:______

Address:______Phone:______

Father is: __ Member of the church __ Not member of the church

Mother is: __ Member of the church __ Not member of the church

Applicant is: __ Member of the church __ Not member of the church

5. Did applicant attend Heritage last year? ___Yes ___No (Please complete New Student form)

A ministry of the Tacoma Bible Presbyterian Church

Parent Commitment

1.  We have read the school’s abbreviated doctrinal statement. We are aware that the school’s position is elaborated in the Westminster Confession and The Shorter Catechism, and we agree to have our child trained in accordance with it. We further pledge to keep doctrinal controversy and denominationalism out of the school at all times.

2.  We hereby invest authority in the school to discipline our child according to Biblical guidelines and principles.

3.  We agree to support and comply with school standards and policies.

4.  We agree that if our child should become involved in any dispute with other children in the school, we will not complain to the other parents but will inform appropriate school personnel and allow them to resolve the matter without interference.

5.  We agree that if a conflict should arise with school personnel, we will go directly to the person involved and will not refer such problems to the principal or school board until we have honestly sought out the person concerned.

6.  We agree to pay Heritage Christian School the tuition required for the complete school year in ten monthly payments (Sept. – June). We understand that tuition payments are processed through F.A.C.T.S., a tuition management company. We understand we must sign a contract with F.A.C.T.S. authorizing automatic withdrawals from the family's bank account. If we are unable to make a payment on time, we will contact the school office before the payment becomes late and make other arrangements. We understand that no records will be released till all accounts are current.

7.  We understand that assessments will be made to pay for damages to school property caused by my child (e.g. abuse of books, broken windows, broken equipment/furnishings, etc.).

8.  We give our permission for our child to participate in all scheduled school-sponsored activities, including field trips. We understand that there are risks with any activity, and we assume full responsibilities for risks and liabilities that may arise from our child participating in school activities.

Parent Signature:______Date:______

Parent Signature:______Date:______

Student Commitments

1.  I promise to obey school rules and school authorities.

2.  I promise to give my best effort in all school activities.

3.  I promise to treat all people and property with respect.

Student Signature:______Date:______

(Parent may sign for child entering grades K-2 after discussing Student Commitments)

A ministry of the Tacoma Bible Presbyterian Church

New Student Information

Heritage Christian School

5412 67th Ave. W., University Place WA 98467 Phone: (253) 564-6276 Fax: (253) 460-1695 www.heritagecs.net

Date:______For School Year: 20_____ to 20______Entering Grade: ______

Student Name:______Date to start at HCS:______

List schools previously attended (including home school), beginning with the most recent school. Kindergartners may list day care, if applicable.

Date or Grade(s) / Name of
School / Address and
Phone Number / Reason for
Withdrawal / Average Grades

Please check all that applies: Please elaborate as necessary:

In school my child performs at:

__ full potential

__ less than full potential

__ not sure

My child has been:

__ retained in a grade

__ double promoted (skipped a grade)

__ tested for learning disabilities

__ placed in the gifted program

__ placed special education

__ in remedial learning environment

__ disciplined frequently at school

__ suspended from school

__ expelled or asked to withdraw

from a school

__ in trouble with the law

__ arrested

__ charged or convicted of a crime

Other information that will help us know and serve your child better: ______

______

A ministry of the Tacoma Bible Presbyterian Church

References

Please provide names of three adults who interact with your child on a regular basis. These adults should not be relatives. The first reference needs to be a spiritual leader (pastor, youth pastor, Sunday School teacher, etc.), the second a school leader (teacher, principal, tutor, etc.), and the third can be a general reference.

Name / Phone(s) / Relation to Applicant / Years
Known
Spiritual leader:
School leader:
General:

Short Answer Questions

An ideal educational situation is one in which the home and the school share common goals and approach to education. We encourage you to carefully evaluate HCS's approach to education. We invite you to share with us your beliefs about education by briefly answering the questions below on a separate sheet(s) of paper and attach to the end of the application.

(Parents of multiple applicants: complete essay for oldest child only and attach to his/her application.)

Parent Questions:

1. What is your religious/spiritual background?

2. In your understanding, what must a person do to have a right relationship with God?

3. What goals do you have for the training and development of your child?

4. What is your role in your child’s education?

5. What are your reasons for wanting to enroll your child at HCS?

Student Applicant’s Questions (for students entering 6th, 7th, or 8th grade only):

11. Describe your relationship to your parents.

12. Describe your relationship to God.

13.  What do you like best about school? What do you like least?

14.  How do you feel about coming to Heritage Christian School?

A ministry of the Tacoma Bible Presbyterian Church

Health/Emergency Record

Heritage Christian School

5412 67th Ave. W., University Place WA 98467 Phone: (253) 564-6276 Fax: (253) 460-1695 www.heritagecs.net

Date:______For School Year: 20_____ to 20______Entering Grade: ______

Student Name:______Date of Birth: ____/____/____ Age:______

Address:______City:______Zip:______Phone:______

Parent:______Work Phone:______Cell/pager:______

Parent:______Work Phone:______Cell/pager:______

Medical History: Please check all conditions that apply to your child. Give brief explanation and instructions.

__ Allergies to medication

__ Allergies (other)

__ Asthma

__ Attention Deficit Disorder (ADD)

__ Attention Deficit and Hyperactivity

Disorder (ADHD)

__ Blood disease

__ Diabetes

__ Emotional problems

__ Epilepsy/Convulsions

__ Frequent headaches

__ Frequent stomach aches

__ Frequent nosebleeds

__ Glasses/contact lenses

__ Hearing impairment

__ Heart abnormality

__ Nervousness

__ Physical disability

__ Sinus problems

__ Other (please specify)

Date of last Tetanus Shot: ______

List all medications your child is taking:______

Does your child have needs or problems that require special handling from the school (e.g. in PE classes, athletic events, etc.)?______

______

(over please)

A ministry of the Tacoma Bible Presbyterian Church

Emergency Information

Alternate Contacts: please list at least two alternate persons to contact if parents/guardians cannot be reached.

Name / Phone / Relationship to Student / Permission to pick up child?
Yes No
Yes No
Yes No
Yes No

Medical Providers: please provide information for preferred medical providers.

Name / Address / Phone
Doctor:
Dentist:
Hospital:

Medical Insurance. All students attending Heritage Christian School are recommended to have adequate medical insurance coverage. The school does not assume responsibility for such coverage. Providing the insurance company and policy number is optional, but it will expedite medical treatment in an emergency.

Insurance Company:______Policy Number:______

Medical Treatment. If your child should become ill while in school, the school will contact the parent/guardian (or one of the alternates provided). In an emergency situation, the school may call the fire department aid car and your child will be treated or transported to a hospital.

Medical Release: In an emergency situation in which immediate treatment is required, I authorize Heritage Christian School to obtain all necessary emergency treatment, including transporting my child to a medical facility. I accept full responsibility for any financial indebtedness related to transporting and treating my child at a hospital or medical clinic.

Parent/Guardian signature:______Date:______

Parent/Guardian signature:______Date:______

A ministry of the Tacoma Bible Presbyterian Church