REGISTRATION FORM ZION TEMPLE CHRISTIAN ACADEMY 3771

REGISTRATION FORM
ZION TEMPLE CHRISTIAN ACADEMY
3771 Reading Road
Cincinnati, Ohio 45229
APPLICATION INFORMATION(PLEASE PRINT)
ALL FEES ARE NON-REFUNDABLE
COPY OF BIRTH CERTIFICATE MANDATORY
ORIGINAL MUST BE ALSO VIEWED
Child’s Name: ___________________________________________________________
First
Middle
Male
Female
Last
Address: ________________________________________________________________
Do you live in the
Cincinnati Public School
District? Yes ____ No ____
Number and Street
____________________________________________________________
City or Town
State
Zip Code
Telephone # _____________________
Social Security # _________/_____/________
Date of Birth: _____________________
Place of Birth: __________________________________________
Last school attended: _____________________
Number of years attended __________
School Address: ___________________________________________
Present grade level ______
District _______________________________
(Please circle only one Grade level & School year)
Grade Applying to Pre-K3, Pre-K4, KDG, 1st, 2nd, 3rd, 4th, 5th, 6th
A.
B.
C.
D.
2016/ 2017/ 2018/ 2019 /2020 /2021 /2022/ 2023
in Yr. 2017/ 2018/ 2019 /2020/ 2021/ 2022/ 2023/ 2024
Grades have been:
Above Average ( )
Average ( )
Below Average ( )
Has child attended or been recommended for a Special Education class?
YES______
Circle Grade(s) previously attended at this school:
K3 K4 K5 1st 2nd 3rd 4 th 5th 6th
Has student failed any grade? ______
NO______
FAMILY INFORMATION
Father’s Name: __________________________________________________________________________________
FIRST
MIDDLE
Occupation: ______________________________
LAST
Company: _____________________________________________________
Home Address (If different than above): __________________________________________
Phone: ____________________
Business Address: ___________________________________________________________
Phone: ____________________
Email Address: _____________________________________________________________ Cell Phone #____________________
Mother’s Name: ___________________________________________________________________________________________
FIRST
MIDDLE
LAST
Home Address (If different than above): ___________________________________________
Occupation: ________________________________
Phone: ____________________
Company: ___________________________________________________
Business Address: _____________________________________________________________
Phone: ____________________
Email Address: ______________________________________________________________ Cell Phone # ___________________
Marital Status: (CIRCLE ONE): MARRIED
WIDOW/WIDOWER
DIVORCED
SEPARATED
If divorced, who has custody? _________________________________________________________
(Registration Form)
SINGLE
MATERNAL GRANDPARENTS
PATERNAL GRANDPARENTS
Name: _________________________________________
Name: __________________________________________
Address: ________________________________________
Address: _________________________________________
Phone: _________________________________________
Phone: __________________________________________
PRIMARY PERSON TO CONTACT IN CASE OF EMERGENCY:
Name: ______________________________________________
Relationship: _____________________________________
Address: _____________________________________________
Phone: ___________________________
Other Emergency Numbers:
Brothers / Sisters of School Age:
Name: _______________________________________
Phone: _____________________
Name: _______________________________________
Phone: _____________________
______________________________________________________________________________
Name
Age
Present School
______________________________________________________________________________
Name
Age
Present School
______________________________________________________________________________
Name
Age
Present School
______________________________________________________________________________
Name
Age
Present School
GENERAL INFORMATION
Is there any mental or physical health condition past or present that we should be aware of? __________
If so, please explain:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
How did you hear about Zion Temple Christian Academy? Radio___ TV___ Internet ___ Day Care Provider ____ School Sign___
Magazine_____________________ Family/Friend_____ Other please indicate___________________________________________
Reasons for sending your child to a Christian School: _______________________________________________________________
___________________________________________________________________________________________________________
RELIGIOUS INFORMATION
Church Affiliation: __________________________________________________________________________________________
Address: _____________________________________________________________________
Signature: _________________________________________________________
Parent or Guardian
Date Entering School:
Registration Payment(s) as follows: $
Phone: _____________________
Date ______________________________
Will Return Registration Forms on:
Registrar’s Initials:
Circle Documentation Received: Birth Certificate Social Security Cards Shot Records
(Registration Form)
Form
ZION TEMPLE CHRISTIAN ACADEMY
TEACHER INFORMATION CARD/B & ASW
(PLEASE PRINT CLEARLY)
DATE_________________________________
Name: ___________________________________________________________________
Last
First
Address: __________________________________________________________________
Age (
) _________________________
Grade applying for: _____________
Middle
Phone: ______________________
Place of Birth: _______________________________ Male______ Female______
Date of Birth (mm/dd/yy)
Will your child (ren) be in the Before School Watch? Yes___ No ___
After School Watch? Yes___ No ___Time_______
Child’s Physician: __________________________________________ Phone __________________
School Ins. __________
Any physical difficulties: ____________________________________________________________________________________
Last School Attended: _______________________________________________________________________________________
Circle grades previously attended at this school:
K3 K4 K5 1st 2nd 3rd 4th 5th 6th
Has child attended a Special Education Program or been recommended for one? Yes _______
No _________
Grades have been: Superior ( )
Above Average ( ) Average ( ) Below Average ( )
Child has failed ( )
Name and grades of other children attending this school: ___________________________________________________________
______________________________________________________________
Church you now attend: _____________________________________________ Attend Sunday school? _________________
Father’s Name: _________________________________ Employer: _______________________ Phone: _________________
Father's Email Address:_____________________________________________________ Cell Phone:_______________________
Mother’s Name: _________________________________ Employer: _______________________ Phone: ________________
Mother's Email Address: ____________________________________________________ Cell Phone: ______________________
If parents are separated, with whom does the child reside? __________________________________________________________
Emergency Contact: _______________________________________________________________________________________
Additional Information that would be helpful to the teacher: ________________________________________________________
_________________________________________________________________________________________________________
PLEASE LIST NAMES OF EVERYONE ALLOWED TO PICK UP YOUR CHILD.
NAME
PHONE NUMBER
NAME
`
PHONE NUMBER
__________________________________
______________
__________________________________
_______________
__________________________________
______________
__________________________________
_______________
__________________________________
______________
__________________________________
_______________
__________________________________
______________
___________________________________
_______________
If there is information that needs to be added on this form, please add to duplicate also. Please see office and teacher(s).
Revised 02/16)
ZION TEMPLE CHRISTIAN ACADEMY
SIGNATURE AND DATE IS REQUIRED WITH CHILD’S NAME. PLEASE DO NOT ADD TO OR TAKE
AWAY FROM THESE STATEMENTS.
DISCIPLINE STATEMENT
I agree to authorize the Administrator or the assigned teacher of the Zion Temple Christian Academy to
exercise authority as to control behavior and discipline over ______________________, while at
Student’s name
school or during any school activity outside school as they deem necessary.
__________________________________________________________________
Parent’s Signature
Date
STATEMENT OF CO-OPERATION
In making application for my child, it is my desire to have him/her complete the school year 20____ 20____. It is also my understanding that the policy of the school is to make no refunds on
registration fees. I also give permission for my child to take part in all school activities, including sports
and school-sponsored trips away from the school premises, and absolve the school from liability to me or
my child because of any injury to my child at school and during any school activity.
__________________________________________________________________
Parent’s Signature
Date
STATE ACCREDITATION
Due to some of the questions in the past concerning State Accreditation, we want to take this opportunity
to clarify. We are NOT accredited by the State of Ohio, which would give them the right to tell us how to
operate our school, what to teach etc. We do however; we are accredited by the National Private
Schools Accreditation Group Inc. and we follow the State requirements concerning required number of
credits and subjects for graduation.
According to the State Supreme Court ruling in 1976, any parent with very strong religious convictions
has the right to put their child in a private school.
We want to make this very clear about this matter. If you understand and comply with the above, please
sign this form and return it to the school office.
__________________________________________________________________
Parent’s Signature
Date
Thank You,
Zion Temple Christian Academy
Three Signature Form
ZION TEMPLE CHRISTIAN ACADEMY
To parents whose child(ren) are not in the extended After School Watch Program:
Parents whose child(ren) are not enrolled in the extended After School Watch program will
have to request a Job Verification form that would require a job letterhead from both parents to
receive the free child watch service between 3:00 p.m. - 4:00 p.m.
To assist working parents with after school pickup, we are requesting a letterhead from
your job with work phone number and statement of time you are released, and your
providing us with your expected arrival time.
This after 3:00 p.m. service is intended for the working parents only and it will become
impossible for the school to provide it if you do not cooperate by conforming to the specific
time requirements. An $8.20 fee is required for an after 4 p.m. pickup. A $8.20 charge
beginning with 1 minute late within each 5 minute segment after 6:00 p.m. On the second
occasion the same cost as the 1st tardy with a note stating that the 3rd late charge will be $25.00
per minute late within each 5 minute segment. School is dismissed at 3:00 p.m. and parents
are expected to pick their child(ren) up at that time if not in the extend watch program.
Thank you in advance for your cooperation in helping us to maintain an effective after school
service.
_______________________________________________
Child’s Name
______________
Grade Level
Please circle below for appropriate pickup time
3:00 - 3:15 p.m.
3:15 - 3:30 p.m.
3:30 - 3:45 p.m.
3:45 – 4:00 p.m.
Comments:
____________________________________________
Parent/Guardian Signature
_____________________
Date
Job Verification
COST CHARTS/PARENT WORKSHEET AND CHECKLIST 2016/17
Prek3
Prek4
K5
1st
2nd
3rd
4th
5th
6th
139.68
134.68
139.68
134.68
139.68
134.68
139.68
134.68
139.68
134.68
139.68
134.68
139.68
134.68
139.68
134.68
139.68
-0-
-0-
44.13
44.13
44.13
44.13
44.13
44.13
44.13
32.29
32.29
32.29
32.29
32.29
32.29
32.29
32.29
32.29
51.70
105.00
160.455
336.90
321.25
301.45
305.55
285.65
290.75
223.67
276.97
271.97
376.55
371.55
553.00
548.00
537.35
532.35
517.55
512.55
521.65
516.55
501.75
496.75
506.85
501.85
Initial Fees Work chart for Enrollees
Registration (Re-Enrollee $134.68)
Testing Fees K5 & Up
Student Promotional Fee
Book Fee
Total/Sub Total_____________
Re-Enrollees ONLY
Before School Watch 7am-8am
Registration Fee $17.22/family
After School Watch 4pm-6pm
Registration Fee $17.22/family
INITIAL FEE TOTAL
(New Enrollees)
All registrants registered now thru May 31st will receive registration and tuition fees at the
old rate. Registrations beginning June 1st will be charged the new rate increase. Reflected in
the above new rates is a $5.00 discount for re-enrollees.
501.75
506.85
THE TUITION CHART BELOW MAY BE USED BY BOTH NEW ENROLLEE AND
RE-ENROLLEE
PARENTS TO
CALCULATE
AND AS CHECKLIST
216.10
216.10
216.10
216.10
216.10.
DISCOUNTS MAY NOT BE COMBINED. FLEXIBLE PAYMENT PLAN SET UP THROUGH FACTS TUITION MANAGEMENT.
216.10
223.67
276.97
376.55
553.00
537.35
517.55
521.65
FFFF
TUITION: Please use this
monthly chart for your final
calculations of tuition, program
fees, awards, and discounts...
AUGUST 20 (typical tuition only)
Please use Promissory Agreement worksheet before using as checklist below. Calculate all monthly fees
and divide by 10 for your monthly payments.
Tuition $___________ BSW $_____________ ASW $____________
Tuition aware $_____________, Family discount award $_____________
483.25
483.25
385.35
374.05
374.05
374.05
374.05
374.05
374.05
4,832.50
4,832.50
3,853.50
3,740.50
3,740.50
3,740.50
3,740.50
3,740.50
3,740.50
SEPTEMBER 1st thru 30TH
OCTOBER 1st thru 31st
NOVEMBER 1st thru 30th
DECEMBER 1st thru 31st
JANUARY 1st thru 31st
FEBRUARY 1st thru 28th
MARCH 1st thru 31st
APRIL 1st thru 30th
MAY 1st thru 30th
TUITION TOTALS ONLY
ZION TEMPLE CHRISTIAN ACADEMY
3771 Reading Road
Cincinnati, Ohio 45229 (513) 861-5551
PROMISSORY AGREEMENT
In order to keep the school afloat, all bills must be promptly paid. Since our tuition is very reasonable, being on
time with monthly fees are essential. The first tuition is due in August to FACTS. You may refer to cost sheet and
financial policy for more information.
Do you have a scholarship? Yes___ No___ Amount $_______. Do you qualify for a discount? Yes__ No __
After completing columns A, B, and C, please calculate row number 8 and place the total in column D8.
This will be your ten month total. Divide it by 10 to see your averaged monthly tuition payment.
(A
Print Child (ren)’s Full Name (s)
Expected Grade
Level(s)
Annual (10 Months)
Tuition Amount
Pre-school
$4,832.50 **
K5 $3,853.50**
Grades 1 thru 6th
$3,740.50 **
(b
BSW or ASW
Ea. program
$1,107.50 **
7am – 8am or
4pm – 6pm
(D
(c
BSA & ASW
Two programs
$1,977.60 **
7am – 8am or
4pm – 6pm
Total Cost of
Tuition annually
1
2
3
4
Subtotals
5
Subtract Year’s Discount if you qualify in column (A5
Difference
_
6
7
Subtract Full Scholarship In column (A7
_
8
Place The Difference In column (A8
Bring B/ASW Totals Down To Row 8
To qualify for the family tuition discount you must have two children enrolled at ZTCA
who are not in the pre-school department.
**************************************** INCREASEED RATES ****************************************
PLEASE NOTE: ALL FEES ARE NONREFUNDABLE.
___________________________ ____________ ______ ______
Street Address
City
State Zip
Day Ph. No. ___________________
Eve Ph. No. ___________________
Cell Ph. No. ___________________
………………………………………………………………………………………………………………………………………
I AGREE WITH HIGH PRIORITY TO AUTHORIZE REGULAR MONTHLY ACH PAYMENTS OF
$_____________ TO FACTS SERVICES ON BEHALF OF ZION TEMPLE CHRISTIAN ACADEMY FOR MY
CHILD’S/CHILDREN’S TUITION/BEFORE AND OR AFTER SCHOOL WATCH FEE(S) BEGINNING
AUGUST, 2016 THROUGH MAY, 2017.
____________________________________
Signature
DATE
___________________________________________
Signature 2
DATE
____________________________________
Print Name
___________________________________________
Print Name 2
Thank you for choosing Zion Temple Christian Academy
ALTERNATE MONTHLY BSW/ASW RATES
SCHOOL YEAR 2016/17
BSW/ASW – 4-5 DAYS WEEKLY = $197.76 Both Programs
BSW/ASW – 4-5 DAYS WEEKLY = $110.75 One Program
BSW/ASW – 3 DAYS WEEKLY = $72.32
BSW/ASW – 2 DAY WEEKLY =
$49.72
BSW/ASW - 1 DAY WEEKLY =
$30.51
Occasional one day Rate is $8.20 for the BSW and the ASW.
Ohio Department of Job and Family Services
CHILD MEDICAL STATEMENT FOR CHILD CARE
Child’s Name (print or type)
Date of Birth
This above named child has been examined, the immunization status recorded, and the child is in suitable condition for participation
in group care.
Signature of Examining Physician/Physician's Assistant/Advanced Practice Nurse/Certified Nurse
Practitioner
Name of Physician/Physician's Assistant/Advanced Practice Nurse/Certified Nurse Practitioner
Date of Examination
Telephone Number
Street Address
City, State and Zip Code
ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD WITH DATES OF DOSES OF ALL IMMUNIZATIONS
PHYSICIAN /PHYSICIAN'S ASSISTANT/ADVANCED PRACTICE
NURSE/CERTIFIED NURSE PRACTITIONER COMPLETES
check all that apply for each disease
Diseases for Immunization
Immunized
In Process of Immunization
Medically Contraindicated/
Not Age Appropriate
Chicken pox
Diphtheria
Haemophilus influenzae type b
Hepatitis A
Hepatitis B
Influenza
Seasonal Vaccine Not Available
Measles
Mumps
Pertussis
Pneumococcal disease
Poliomyelitis
Rotavirus
Rubella
Tetanus
I have declined to have my child immunized against one or more of the diseases required by 5104.014 of the Ohio Revised Code. Initial beside the
disease(s) being declined above and sign below.
Signature of Parent
Date of Signature
Recommended Assessments/Screenings
Vision
Yes
No
Lead
Yes
No
Hearing
Yes
No
Hemoglobin
Yes
No
Dental
Yes
No
Measurements:
Height
Weight
BMI
JFS 01305 (Rev. 6/2015)
Other
Notes:
Reset Form
Zion Temple Christian Academy
CHILD ENROLLMENT AND HEALTH INFORMATION
FOR CHILD CARE CENTERS AND TYPE A HOMES
This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Child’s Name
Date of Birth
First Day at Center
Home Address
State
City
Zip Code
Home Telephone Number
Parent/Guardian Name
Relationship to Child
Home Address
Home Telephone Number
City
State
Zip
Email Address (if applicable)
Cell Phone
Parent's Work/School Telephone Number
Parent's Work/School Name
Parent's Work/School Address
City
Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact
information for other parents/guardians.
Yes
No
If you answered yes, please indicate which number(s) above to include on the list
Work #
Cell #
Home #
Email
Where can you be reached while your child is in this program?
Parent/Guardian Name
Relationship to Child
Home Address
Home Telephone Number
City
State
Email Address (if applicable)
Cell Phone
Parent's Work/School Telephone Number
Parent's Work/School Name
Zip
Parent's Work/School Address
City
Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact
Yes
No
information for other parents/guardians.
If you answered yes, please indicate which number(s) above to include on the list
Work #
Cell #
Home #
Email
Where can you be reached while your child is in this program?
Emergency Contacts: Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted
in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least
one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot
be contacted and should be at least 18 years of age.
Name
Name
City
State
City
State
Telephone Number
Relationship to Child
Telephone Number
Relationship to Child
Other numbers where emergency contact can be reached (if applicable)
Other numbers where emergency contact can be reached (if applicable)
Name of Physician or Clinic/Hospital
Street Address
City
JFS 01234 (Rev. 9/2011)
State
Telephone Number
Page 1 of 3
Child’s Name
Allergies, Special Health or Medical Conditions, and Food Supplements
Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care
staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236
"Medical/Physical Care Plan" or equivalent form and/or the JFS 01217 "Request for Administration of Medication" must be completed
and be kept on file at the center or type A home.
Does your child have any food, medication or environmental allergies? (check all that apply)
No
Yes - check all that apply
Food
Medication
Environmental
Please list and explain:
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or
give emergency medication to your child? (check one)
No
Yes - a JFS 01236 "Medical/Physical Care Plan" or equivalent form and if administering medication, a JFS 01217
"Request for Administration of Medication" must be completed.
Does your child have a special health or medical condition? (check one)
No
Yes - please explain
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care
such as: to monitor your child for symptoms or administer medication during child care hours? (check one)
No
Yes - a JFS 01236 "Medical/Physical Care Plan" or equivalent form and if administering medication, a JFS 01217
"Request for Administration of Medication" must be completed.
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)? ( check one)
No
Yes - please explain
If yes, does this medication, food supplement, or medical food need to be administered at the child care center/type A
home?
No
Yes - a JFS 01217 "Request for Administration of Medication" must be completed and kept on file for each medication,
food supplement or medical food.
N/A - program does not administer any medications.
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one)
No
Yes - please explain
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?
No
Yes - written instructions from the child's health care provider must be on the JFS 01217 "Request for Administration of
Medication."
N/A - child does not attend a full time program.
JFS 01234 (Rev. 9/2011)
Page 2 of 3
Child's Name
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical
personnel in an emergency situation.
List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special
routines. This information should not be medical or health related, as that information should be included on the previous page.
Toilet Training Statement (Preschool)
Is your child toilet trained?
Yes (If yes, skip to Emergency Transportation Authorization section)
accept children who are not toilet trained)
No (If no, we do not
If your child have an accident, parents will be called to pick them up.7KH\PXVWEHSLFNHGXSZLWKLQWKHKRXU
I agree with the program's policy
Emergency Transportation Authorization
Give Permission to Transport
Do Not Give Permission to Transport
Center or Type A Home Name
Center or Type A Home Name
has permission to secure emergency transportation for
my child in the event of an illness or injury which
requires emergency treatment. The emergency
transportation service will determine the facility to which
my child will be transported.
Parent's Signature
Date
OR
Do
not
sign
both
does not have permission to secure emergency
transportation for my child in the event of an illness or
injury which requires emergency treatment. I wish for the
following action to be taken:
Parent's Signature
Date
Acknowledgement of Policies and Procedures
I have reviewed and received a copy of the center's or type A home's policies and procedures/handbook.
(check one)
Yes
No
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the
administrator/designee prior to the child receiving care. After the child is attending the program the administrator shall have
the parent/guardian review and initial the form when any changes/updates are made and at least annually. The parent/
guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was
last reviewed.
Parent/Guardian Signature(s)
Date
Administrator/Designee Signature
Date
The form is to be initialed and dated, at least annually, after it has been reviewed by the parent/guardian. This is to indicate all information
has stayed the same or changes have been noted. If significant changes are needed, please complete a new form.
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Note: This is a prescribed form which must be used by centers and type A homes to meet the requirements of rules 5101:2-12-37 and 5101:2-13-37. This
form must be on file at the center or type A home on or before the child’s first day of attendance and thereafter while the child is enrolled.
JFS 01234 (Rev. 9/2011)
Page 3 of 3
ZION TEMPLE CHRISTIAN ACADEMY
3771 Reading Road – Cincinnati, Ohio 45229
(513) 861-5551 - Fax: (513) 861-1563
District Elder Charles L. Smith, Pastor/Principal
Rodney D. Napier, Assistant Principal
Mary E. Jackson, Director
“Train up a child in the way he should go; and when he is old, he will not depart from it.”
Proverbs 22:6
Photo Release Form
Dear Parents/Guardians:
During the course of the school year there are times when pictures or videos of your child may be
taken, or when he or she may be interviewed while at school, to showcase an event or to detail a
project of his or her grade. These pictures, videos, and interviews may be used for internal and
external audiences. These materials include but not limited to advertisements, brochures, news
releases newspapers, newsletters, yearbook, web sites, and television.
Please complete the form below and return it with your packet or to your child’s teacher. We
appreciate your cooperation.
Sincerely,
Administration
Zion Temple Christian Academy
____ I will only take pictures of my child(ren) and post on social media websites (e.g. Facebook
and Twitter). I will not post pictures of other children without their parents’ permission.
____ I give my permission for my child to be photographed, videotaped, or interviewed for all
school purposes, including the Zion Temple Christian Academy web site.
____ I do not give my permission for any photographs, videotapes, or interviews of my child to
be published or used for any purpose.
Child’s Name: ___________________________________
Grade: _________________________________________
Parent Signature: _________________________________
Date: __________________________________________