Fillable Fairfield Christian Academy SADC Enrollment Checklist (Fairfield Christian Academy)

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Fairfield Christian Academy SADC Enrollment Checklist (Fairfield Christian Academy)

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Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
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 Name
FAIRFIELD
CHRISTIAN
ACADEMY
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?
Work
Job 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?
Work
Job Title
Employer
Home
Cell
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
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:
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 2
nd
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 Name
FAIRFIELD
CHRISTIAN
ACADEMY
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 PLAY
I 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 Name
FAIRFIELD
CHRISTIAN
ACADEMY
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. e 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 Faireld 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. e 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 insucient funds, will necessitate a $25 returned check fee
along with paying with cash through the oce. I/We realize that failure to meet this nancial agreement will
result in student withdrawal.
For any additional nancial questions please send emails to pmccarty@fcaknights.us.
In 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
Date
Parent/Guardian Printed Name
Parent/Guardian Signature
Date
Parent/Guardian Printed Name
SADC FACTS Agreement
SADC Withdrawal Policy
• Withdrawing prior to July 6, 2020: 50% of total program fee due
• Withdrawing aer July 6, 2020: 100% of program fee due
FORM C
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
BOTH PARENTS/GUARDIANS MUST SIGN UNLESS ONLY ONE HAS ALL CUSTODY RIGHTS
is Release of Liability is executed in consideration for allowing the above-named child to enroll in Faireld Christian
Academy and to participate in activities related to the school. is 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 Faireld Christian
Academy, Faireld Christian Church, and the School Administration, Sta 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 Faireld 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 Faireld Christian Academy,
Faireld Christian Church, and its School Administration, Sta and Volunteers, for any liability sustained by Faireld
Christian Academy, Faireld 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 Faireld Christian Academy’s SADC Parent Handbook on Faireld Christian Academy’s website
and I was provided clear and accurate information regarding all policies and guidelines of Faireld 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 notied 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 Name
FAIRFIELD
CHRISTIAN
ACADEMY
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
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Fairfield Christian Academy SADC Enrollment Checklist (Fairfield Christian Academy)

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Completed 27 February 2021

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