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Fairfield Christian Academy SADC Enrollment …Fairfield Christian Academy SADC Enrollment Checklist...

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  • Child’s NameFAIRFIELDCHRISTIANACADEMY

    Fairfield Christian Academy SADC Enrollment Checklist

    Thank you for your interest in Fairfield Christian Academy’s Summer Adventure Day Camp. To complete the enrollment

    process, please finish each item on the checklist.

    $40 Application Fee (check made payable to FCA)

    Complete and Sign Family and Additional Information

    Complete Emergency Medical Release (Form A)

    Complete Transportation Permission Sheet (Form B)

    Complete FACTS Agreement (Form C)

    Sign Liability Release/Acknowledgment of Policies (Form D)

    Enroll in FACTS online at www.online.factsmgt.com/signin/3CP5 for payment plan

  • Child’s NameFAIRFIELDCHRISTIANACADEMY

    Family Information

    First Contact Spouse

    Street Address City State Zip

    Home Phone Cell Phone Work Phone

    Email Best number you can be reached at during this program?

    WorkJob Title Employer

    Home Cell

    Student resides with: Father/Mother (same residence) Mother (separate residence)Father (separate residence)

    Other:Name (please print) Relationship to Student

    Is either parent (or other) forbidden by court order from having equal access to the child or school records? No Yes

    Copies of custody paperwork must be submitted with this application.

    Has your child ever attended child care, SADC or preschool at FCA?

    Additional Information

    Does your child have any siblings that are currently enrolled in FCA Childcare/Preschool or FCA K-12?

    Has your child ever been diagnosed with a speech or hearing disability?

    No Yes

    Where does your child attend school and what grade will he/she be entering next school year?

    No Yes If yes, please provide their names:

    No Yes

    What size t-shirt does your child wear?

    Second Contact Spouse

    Street Address City State Zip

    Home Phone Cell Phone Work Phone

    Email Best number you can be reached at during this program?

    WorkJob Title Employer

    Home Cell

  • Child’s NameFAIRFIELDCHRISTIANACADEMY

    List any chronic physical problems and history of hospitalization:

    Does your child wear glasses?

    No Yes

    No Yes

    If yes, where?

    List any diseases that your child has had:

    Do you attend church? No Yes

    Has your child ever been dismissed or asked to leave a school or child care facility?

    If yes, please explain

    Has your child ever been tested for behavioral, emotional or psychological conditions or any other conditions

    that require specialized care? No Yes

    If yes, please explain

    Do you feel there are any characteristics relating to the health or personality of your child that may be

    helpful to your child’s teacher? No Yes

    If yes, please explain

    Please select the appropriate race/ethnic class for your child (The IRS and Ohio Reporting requirement

    request this information).

    African American

    I do not wish to provide this information

    Native American

    Hispanic

    White

    Multi-racial

    Asian

    Race/Ethnicity

    Parent/Guardian Signature Date

  • FORM A

    Emergency Medical Authorization

    CHILD’S NAME__________________________

    PLEASE PRINT and use BLACK or BLUE Ink ONLY: Student Name

    Gender

    Date of Birth

    Grade

    Primary Number

    Street Address

    City

    State

    Zip

    Section 3313.712 of the Ohio Revised Code requires the following: Purpose – To ENABLE parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority when the parents or guardians cannot be reached. Part 1 or Part 2 MUST BE COMPLETED.

    Part 1 (To Grant Consent)

    In the event reasonable attempts to contact me or the other parent/guardian listed below at the numbers provided have been unsuccessful, I HEREBY GIVE MY CONSENT for (1) the administration of any treatment deemed necessary by the preferred physician or preferred dentist listed below, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and, (2) the transfer of the child: outside of Fairfield County to the nearest emergency facility, or in Fairfield County, to Fairfield Medical Center. If the situation necessitates transport to another facility, those arrangements would be made through Fairfield Medical Center or the facility outside of Fairfield County to which the child has been transported. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Please complete answers below to which the physician should be alerted:

    ALLERGIES Y/N Please explain “yes” answers

    Environmental

    Food

    Insects (bees)

    Medication

    IS HE/SHE ON MEDICATION (prescription and over-the-counter medication the child takes on a regular basis)?

    Medications (Name and Strength) Dose/Frequency Days Taken Home School

    MEDICALCONDITIONS: _________________________________________________________________________________________________ _____________________________________________________________________________________________________________________

    1st Contact

    Parent/Guardian

    2nd Contact (If no 2nd Parent/Guardian, List Alternative Contact)

    Preferred Physician Preferred Dentist

    Name

    Relationship

    Home Phone

    Cell Phone

    Work Phone

    _____________________________________________________________________ ____________________

    Parent/Guardian Signature Date

    Part 2 ( Refusal To Consent) DO NOT COMPLETE Part 2 IF YOU HAVE COMPLETED Part 1

    I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to TAKE NO ACTION OR TO:

    _____________________________________________________________________ ____________________

    Parent/Guardian Signature Date

  • Child’s NameFAIRFIELDCHRISTIANACADEMY

    I give ONLY the following people permission to pick up my child from Summer Adventure Day Camp. Please list all possible persons at this time. Please be sure to include yourself, spouse and those whom you have listed as emergency contacts. The office must receive additional requests in writing prior to the day that a new person will be picking up your child.

    Parent/Guardian Signature Date

    Transportation Permission

    Name Phone Number Relationship to Child

    Part-Time

    Full-Time

    Please Check a Summer Adventure Day Camp Program

    1-3 Days

    4-5 Days

    I give permission for my child to be included in videotaping and photos to be used by Fairfield Christian Academy.I do not give permission for my child to be included in videotaping and photos to be used by Fairfield Christian Academy.

    PHOTO RELEASE

    PERMISSION TO PARTICIPATE IN WATER PLAYI give permission for my child to participate in water play at Fairfield Christian Academy. Water depth will not exceed two feet.

    ANNUAL CLASS ROSTER

    I do not give permission for my child to participate in water play at Fairfield Christian Academy.

    I authorize my child’s name, my name and my phone number to be listed on the parent roster.

    I do not authorize my child’s name, my name and my phone number to be listed on the parent roster.

    FORM B

  • Child’s NameFAIRFIELDCHRISTIANACADEMY

    In signing the Statement of Agreement, I/We agree to the following:

    1. Tuition and Fees Financial Policy: Tuition and fees will be charged according to the Schedule of Tuition and Fees adopted by the school for the applicable school year. By signing this contract, I agree to abide by the policies relating to the payment of such tuition and fees.

    2. The person(s) responsible for payment of tuition and fees:

    Name: ______________________________________________________ Phone: ________________________ Email address: ______________________________________________________________________________Billing Address: _____________________________________________________________________________

    3. For the summer, I will pay my child’s tuition through the option checked below: Option #1 - Full Tuition: Due May 17, 2020 - Payment will be made through the FACTS payment plan. No FACTS fee will be assessed. Option #2 - Full Tuition: Due May 17,2020 - Payment will be made by cash or check to Fairfield Christian Academy. Option #3 - Monthly Payments: Two or three monthly payments through FACTS only. (NO cash or check option for monthly payments.) Parents who use the automated process of tuition payments may elect to pay tuition on the 5th or 20th of each month through the FACTS payment plan. The FACTS annual enrollment fee is $45. I/we agree to complete the FACTS agreement for online.

    I/we understand that for any student withdrawals, a two week notice is required with two week tuition payments. Any subsequent changes in my payment option will result in a $20 administrative charge. I/we further understand that checks returned from the bank for insufficient funds, will necessitate a $25 returned check fee along with paying with cash through the office. I/We realize that failure to meet this financial agreement will result in student withdrawal. For any additional financial questions please send emails to [email protected] signing this Statement of Agreement, I/we agree that I am/we are responsible for payment of all tuition and fees for the child covered by this agreement.

    Parent/Guardian Signature DateParent/Guardian Printed Name

    Parent/Guardian Signature DateParent/Guardian Printed Name

    SADC FACTS Agreement

    SADC Withdrawal Policy• Withdrawing prior to July 6, 2020: 50% of total program fee due• Withdrawing after July 6, 2020: 100% of program fee due

    FORM C

  • Child’s NameFAIRFIELDCHRISTIANACADEMY

    BOTH PARENTS/GUARDIANS MUST SIGN UNLESS ONLY ONE HAS ALL CUSTODY RIGHTS

    This Release of Liability is executed in consideration for allowing the above-named child to enroll in Fairfield Christian Academy and to participate in activities related to the school. This Release of Liability must be signed by BOTH parents/guardians unless only one parent/guardian has all custody rights.

    We/I, on behalf of our/my child do hereby release and forever discharge and agree to hold harmless Fairfield Christian Academy, Fairfield Christian Church, and the School Administration, Staff and Volunteers, from any and all loss, liability, claims, or demands of any nature, including but not limited to negligence, which may be incurred by the undersigned, and the child while he/she is enrolled at Fairfield Christian Academy.

    Furthermore, we/I and on behalf of our/my child assume all risks of personal injury, sickness, death, damage, and expenses as a result or participation in recreation, study, and school-related activities in which the designated child is involved.

    We/I, the undersigned, further hereby agree to hold harmless and indemnify Fairfield Christian Academy, Fairfield Christian Church, and its School Administration, Staff and Volunteers, for any liability sustained by Fairfield Christian Academy, Fairfield Christian Church as a result of the negligent, willful, or intentional acts of the named child, including any related expenses.

    Liability Release

    I reviewed a copy of the Fairfield Christian Academy’s SADC Parent Handbook on Fairfield Christian Academy’s website and I was provided clear and accurate information regarding all policies and guidelines of Fairfield Christian Academy’s SADC program. I understand the policies and guideline by which the center operates.

    I agree to abide by all policies stated in the parent handbook. I understand that I will be notified of any changes made to these policies.

    I also understand that any breach of the center’s policies may be grounds for withdrawal from the program. A two week notice will be provided in such a circumstance unless the infraction is severe enough to warrant termination without notice.

    I further understand that failure to be prompt and accurate with payment will be grounds for withdrawal.

    Acknowledgment of Policies

    Parent/Guardian Signature Date

    Parent/Guardian Signature Date

    Parent/Guardian Signature Date

    FORM D

  • Child’s NameFAIRFIELDCHRISTIANACADEMY

    Sunscreen Release Form

    Nonprescription medication

    Prescription medication

    Refrigeration required Modified diet

    Food Supplement

    Topical product or lotion

    Complete all of the following information:

    Child’s Name

    Date of Birth

    Name of Medication sunscreen

    To be administered at the following times: as needed

    For the following period of time: June 1, 2020 - August 7, 2020

    Parent/Guardian Signature Date

    1 SADC To Do Checklist2 SADC Family Information3 Page 34 Emergency Medical Authorization FORM A5 Transporation Permission FORM B6 SADC FACTS Agreement - FORM C7 Liability Release - FORM D8 SADC Sunscreen Release Form4 Emergency Medical Authorization FORM A.pdfUntitled

    Childs Name: Phone: Email Address: Billing Address: Option 1 Full Tuition Due May 17 2020 Payment will be made through the FACTS payment plan: OffOption 2 Full Tuition Due May 172020 Payment will be made by cash or check to Fairfield Christian: OffOption 3 Monthly Payments Two or three monthly payments through FACTS only NO cash or check: OffParentGuardian Printed Name: ParentGuardian Printed Name_2: Prescription medication: OffNonprescription medication: OffRefrigeration required: OffTopical product or lotion: OffFood Supplement: OffModified diet: OffChilds Name_2: Does your child wear glasses: Offundefined: OffIf yes where: Has your child ever been dismissed or asked to leave a school or child care facility: OffIf yes please explain: that require specialized care: OffIf yes please explain_2: helpful to your childs teacher: OffIf yes please explain_3: I do not wish to provide this information: OffAfrican American: OffHispanic: OffNative American: OffMultiracial: OffWhite: OffAsian: OffPhysical Problems: Diseases: First Contact: Spouse: Email: Job Title: Home: OffCell: OffWork: OffEmployer: Second Contact: Spouse_2: Street Address_2: City_2: State_2: Zip_2: Home Phone_2: Cell Phone_2: Work Phone_2: Email_2: Job Title_2: Home_2: OffCell_2: OffWork_2: OffEmployer_2: FatherMother same residence: OffFather separate residence: OffMother separate residence: OffOther: Relationship to Student: Is either parent or other forbidden by court order from having equal access to the child or school records: OffHas your child ever attended child care SADC or preschool at FCA: OffWhere does your child attend school and what grade will heshe be entering next school year: Does your child have any siblings that are currently enrolled in FCA ChildcarePreschool or FCA K12: OffIf yes please provide their names: Has your child ever been diagnosed with a speech or hearing disability: OffWhat size tshirt does your child wear: 40 Application Fee check made payable to FCA: Complete and Sign Family and Additional Information: Complete Emergency Medical Release Form A: Complete Transportation Permission Sheet Form B: Complete FACTS Agreement Form C: Sign Liability ReleaseAcknowledgment of Policies Form D: Enroll in FACTS online at wwwonlinefactsmgtcomsignin3CP5 for: NameRow1: Phone NumberRow1: Relationship to ChildRow1: NameRow2: Phone NumberRow2: Relationship to ChildRow2: NameRow3: Phone NumberRow3: Relationship to ChildRow3: NameRow4: Phone NumberRow4: Relationship to ChildRow4: NameRow5: Phone NumberRow5: Relationship to ChildRow5: NameRow6: Phone NumberRow6: Relationship to ChildRow6: NameRow7: Phone NumberRow7: Relationship to ChildRow7: NameRow8: Phone NumberRow8: Relationship to ChildRow8: NameRow9: Phone NumberRow9: Relationship to ChildRow9: PartTime: OffFullTime: OffI give permission for my child to be included in videotaping and photos to be used by Fairfield: OffI do not give permission for my child to be included in videotaping and photos to be used by Fairfield: OffI give permission for my child to participate in water play at Fairfield Christian Academy Water depth: OffI do not give permission for my child to participate in water play at Fairfield Christian Academy: OffI authorize my childs name my name and my phone number to be listed on the parent roster: OffI do not authorize my childs name my name and my phone number to be listed on the parent roster: OffCHILDS NAME: Student Name: Gender: Date of Birth: Grade: Primary Number: Street Address: City: State: Zip: Part 1 To Grant Consent: ALLERGIES: YN: Y/N: MEDICALCONDITIONS 1: MEDICALCONDITIONS 2: 2nd Contact: Home Phone: Cell Phone: Work Phone: school authorities to TAKE NO ACTION OR TO 1: school authorities to TAKE NO ACTION OR TO 2: Please explain yes answers: Medications Name and Strength: Name: Relationship: Dose: Days Taken:

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