Fillable Fairfield Christian Academy School Age Care Enrollment Checklist (Fairfield Christian Academy)

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Fairfield Christian Academy School Age Care Enrollment Checklist (Fairfield Christian Academy)

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  • 9 signatures
  • 10 check-boxes
  • 198 other fields

Country of origin: US
File type: PDF

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Fairfield Christian Academy School Age Care
Enrollment Checklist
Thank you for your interest in our school age care program. To complete the
enrollment process, please indicate which program you are interested
in and finish each item on the checklist below.
Days and times of program are indicated on Form B
AM Sonzone
PM Sonzone
Summer Care
Complete the Pick-up List (Form B)
Complete the FACTS Agreement (Form C)
Sign the Liability Release/Acknowledgment of Handbook (Form D)
Child’s Name
Child’s DOB
School Year
The Sonzone program is only available on days that FCA K-12 is in session.
Forms checklist for NEW families
Forms checklist for ALL applicants
For returning FCA families
Sign use of current records form (Form E)
Complete and Sign the Family Information and Student Profile
Custody Agreement Documents (if applicable) Complete the
Emergency Medical Authorization (Form A)
Child Medical Statement (Must be signed by your child’s physician)
Submit immunization records from your child’s physician
Enroll in FACTS online at www.online.factsmgt.com/signin/3CP5
Child’s Name
Spouse
City
State
Zip
Cell Phone
Work Phone
First Contact
Street Address
Home Phone
Email
Job Title
Home
Cell
Work
Father/Mother (same residence)
Mother (separate residence)
Father (separate residence)
Student resides with:
Other:
Name (please print) Relationship to Student
Is either parent (or other individual) forbidden by court order from having equal access to the child or
school records? Copies of custody paperwork must be submitted with this application.
If your child a current FCA student?
Does your child have any siblings that are currently enrolled in FCA Childcare/Preschool or FCA K-12?
Yes
No Please explain your child’s previous schooling or child care experiences.
Yes
No
If yes, please provide their names:
Employer
Which phone number should be called first?
Second Contact
Street Address
Home Phone
Email
Spouse
City
State
Zip
Work Phone
Cell Phone
Which phone number should be called first?
Home
Cell
Work
Job Title
Employer
Yes
No
Family Information and Student Profile
Has your child ever been diagnosed with a speech or hearing disability?
Yes No
If yes, please explain:
Child’s Name
List any chronic physical problems and history of hospitalization:
No
Yes
No
If yes, where?
List any diseases that your child has had:
Does your child wear glasses?
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?
Yes
No
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?
Yes
No
If yes, please explain
Optional. Please select the appropriate race/ethnic class for your child (The IRS and Ohio Reporting
requirement request this information).
Native American
Multi-racial
White
I do not wish to provide this information
African American
Hispanic
Asian
Parent/Guardian Signature
Date
Yes
Family Information and Student Profile
Please complete both pages of the form
Emergency Medical Authorization
Revised 5/6/2020
This form meets the requirement for Ohio Revised Code Section 3313.712. Programs may use this form or build their own.
Student Name
Address
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 parents or
guardians cannot be reached.
Residential Parent or Guardian:
Mother's Name
Father's Name
Other’s Name
Name of Relative or Childcare Provider
Relationship
Address
Emergency Contact
1
#1
Address
Emergency Contact #2
Address
Emergency Contact #3
Address
1
Emergency contact information is required in accordance with Ohio Administrative Code Rule
3301-37-08 (for preschool programs) and Rule 3301-32-10 (for school aged child care programs).
FORM A
Program Name
Phone
Daytime Phone
Daytime Phone
Daytime Phone
Daytime Phone
Daytime Phone
Daytime Phone
Daytime Phone
Fairfield Christian Academy School Age Care Program
Please complete both pages of the form
PART I OR II MUST BE COMPLETED:
PART I - TO GRANT CONSENT I hereby give consent for the following medical care providers and
local hospital to be called:
Doctor
Dentist
Medical specialist
Local Hospital
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent
for: (1) the administration of any treatment deemed necessary by above-named doctor, or, in the
event the designated preferred practitioner is not available, by another licensed physician or dentist;
and (2) the transfer of the child to any hospital reasonably accessible. 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.
Facts concerning the child's medical history including allergies, medications being taken, and any
physical impairments to which a physician should be alerted:
Signature of Parent/Guardian
Address
PART II - REFUSAL TO CONSENT 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 the following action (written instructions must be completed):
Signature of Parent/Guardian
Address
Phone
Phone
Phone
Emergency Room Phone
Date
Date
Fairfield Medical Center is the responding hospital to 911 calls placed from FCA.
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signature
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signature
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In Process
Office of Early Learning and School Readiness
Child Medical Statement
Revised 3/12/2018
Section I - Child Medical Information
Child's Name
Date of Birth Height Weight
Immunizations:
Limitations or health conditions, including allergies, medications, and dietary restrictions.
Complete for Age
Yes No
Yes No
Exempt from Immunization:
Religious Conviction
Health
Other
No
NoYes
Yes
This child has been examined and is in suitable condition to participate in group care.
Section II - Child Medical Statement Verification
Provider Address
Provider Phone Number
Physician
Physician Assistant
Advanced Practice Registered Nurse
Signature of Medical Professional Date of Exam
Provider City Provider State
Check box of examining medical professional:
Physician/Clinic/Hospital Name
Provider Zip
Programs funded through the Ohio Department of Education must have written policies and procedures to
ensure that children have received comprehensive health screenings and/or that families are informed of the
importance of health screenings and the resources to obtain them.
This form meets Ohio Administrative Code. Programs may use this form or build their own.
Immunization records can be faxed to:
FCA School Age Care Program
(740)654-7689
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signature
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Child’s Name
Parent/Guardian Signature
Date
Name Phone Number Relationship to Child
Please select all programs for which you are applying
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.
PERMISSION TO PARTICIPATE IN WATER PLAY
I 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.
AM Sonzone
PM Sonzone
Summer Care
ANNUAL CLASS ROSTER
PHOTO RELEASE
Monday - Friday
Monday - Friday
Monday - Friday
6:30 AM - 7:45 AM
3:00
AM - 5:30 PM
7:30 AM - 5:30 PM
FORM B
Permission for Transportation (Pick-Up List)
I give ONLY the following people permission to pick up my child from FCA. 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.
I do not give permission for my child to participate in water play at Fairfield Christian Academy.
SUNSCREEN - Sunscreen must be applied before all outdoor activities.
I will provide sunscreen for my child.
I will not provide sunscreen for my child; sunscreen supplied by FCA may be applied to my child.
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signature
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Child’s Name
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:
Monthly Payments: monthly payments through FACTS only. (NO cash or check payment option.)
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.
Upfront in full
I/we understand that for any student withdrawals, a written two week notice is required with payment in full for
the final two weeks. 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 incur a $25 returned
check fee and require immediate cash payment for all charges due. I/We realize that failure to meet this
financial agreement will result in dismissal.
For any additional financial questions, please email Pam McCarty at 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
FACTS Agreement
FORM C
Name
Email Address
Billing Address
Phone
For the duration of this program period, I will pay my child’s tuition through FACTS by paying:
Child’s Name
Liability Release & Acknowledgment of Handbook
BOTH PARENTS/GUARDIANS MUST SIGN UNLESS ONLY ONE HAS ALL CUSTODY RIGHTS
Signature
Date
Date
FORM D
Parent/Guardian 2
Signature
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.
I acknowledge that a copy of the Fairfield Christian Academy Preschool Parent Handbook has been
provided to me and that is it my responsibility to review the policies and guidelines outlined in the handbook.
The handbook is also publicly available on the FCA website.
I agree to adhere to all of the policies and guidelines of the program as outlined in the handbook. I
understand that I will be notified of any changes made to these policies.
Print Name
Parent/Guardian 1
Print Name
Child’s Name
Signature
Date
FORM E
Use of Current Records
I have reviewed the following forms and information I provided to Fairfield Christian Academy during the
previous school year:
• Student and family profile
• Emergency Medical Authorization
• Child Medical Statement
• Immunization records
I agree that the information in my student's school records is accurate, complete and current to the best
of my knowledge and authorize FCA to use these records as part of my application for the school age
care program. I understand that it is my responsibility to update these records when necessary.
Parent/Guardian
Print Name
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Fairfield Christian Academy School Age Care Enrollment Checklist (Fairfield Christian Academy)

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Completed 25 March 2022

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