1212 Princess Anne Road

Virginia Beach, VA 23457

Telephone (757) 426-3544

Fax (757) 426-0067

Date of application_____________________________________ Date of enrollment______________________

Student’s Full Name:_____________________________________________________________ Grade :________

Last First M.I.

S.S. # ___ ___ ___-___ ___-___ ___ ___ ___ Date of Birth:_____/______/_____ Age______________________

Street Address: __________________________________________________________________________________

City, State and zip code____________________________________________________________________________

Home Phone:____________________________________________________________________________________

e-mail:________________________________________________________________________________

Employer: _________________________________ Work Phone:____________________________________

Employer: _________________________________ Work Phone: ____________________________________

Step-Parent/Guardian Name:__________________ Daytime Phone: _________________________________

I will______ will not__________ allow my child to be photographed for class projects, bulletin boards.

____________________________has my permission to go on all school-approved, teacher-supervised

trips while enrolled at Back Bay Christian Academy.

________________________________________ ___________________________________

Parent/Guardian Signature Date

Please list the names and dosage amounts of any medication your child is currently taking:

______________________________________________________________________________________

I do____do not_____ give consent for emergency medical treatment of my child.

Physician’s Name & Number__________________________ Preferred Hospital___________________

Parent or Guardian Signature ________________________________ Date________________________

Please list the numbers you would like us to call, in the order you would like us to call them, in the event of an emergency, student illness, or school closing.

Name Relationship to Child Phone Number

1. ____________________________ _______________________ ______________

2. ____________________________ _______________________ ______________

3. ____________________________ _______________________ ______________

4. ____________________________ _______________________ ______________

Previous School(s) Attended:_______________________________________________

Phone Number(s) of Previous School(s)_______________________________________

Has the student ever had any learning/discipline problems in school?

If yes, please explain.

Has the student ever repeated a grade?

If yes, please explain.

Does the student have a learning disability?

Please list any school or family situations that we should be aware of (joint custody arrangements, death or serious illness of a family member, etc.)

The following individuals may pick up my child(ren) in an emergency situation:

1. Name:___________________________ Phone:_________________ Cell:______________

2. Name:___________________________ Phone:_________________ Cell:______________

3. Name:___________________________ Phone:_________________ Cell:______________

4. Name:___________________________ Phone:_________________ Cell:______________

5. Name:___________________________ Phone:_________________ Cell:______________

Parent/Guardian Signature_________________________________ Date:___________

PUBLIC DISCLOSURE STATEMENT

The code of Virginia, Section 63.1-196.3, allows child day centers operated by religious institutions the opportunity to file for an exemption from licensure by meeting documentation and other requirements specified within the exemption law. In compliance with the Code of Virginia, this Center is exempt from licensure and is classified as an "Exempt" child day center.

This center is not able to provide food services. Parents/Guardians are responsible for providing a healthy, nutritious snack for their children.

(Must be completed for each child enrolled.)

Student’s Name__________________________________________________________

In the event reasonable attempts to contact me at ______________________________ or _________________ (other parent or guardian) have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by Dr. __________________ (Preferred Physician) or in the event the designated preferred practitioner is not available, by another licensed physician, and the transfer of the child to______________________________ (preferred hospital) or hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Parent or Guardian Signature ________________________________ Date________________________

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 school authorities to take no action or to_____________________________________________ (Specify Action)

Parent or Guardian Signature:__________________________________ Date______________________

In order to help Back Bay Christian Academy personnel in notifying you and the Family Doctor, please give the following information:

Insurance Carrier:______________________ Policy Number:___________________________________

Is the student currently taking any prescription medication?

If so, what kind, and how often?

Does the student have any allergies? If so, explain.

Does your child have a physical, visual, or speech impairment? If yes, please explain.

 

Registration Fee $50

Maintenance Fee (Kindergarten-12^th Grade) $100

Maintenance Fee (Pre-School) $75

Pre-School Book Fee $95

Kindergarten-8th Grade Book Fee $360

9^th-12^th Grade Book Fee $375

All A-Beka textbooks will be the property of the student.

Monday, Wednesday, Friday 1/2 day class (9:00 a.m.-12:00 p.m.) ____ $150

Kindergarten-12^th Grade Tuition may be paid in 2 ways:

1. One lump sum payment due by September 1^st. A 4% tuition discount will be given to those choosing this option. Please note that this option is not available for pre-school tuition.

2. Payment in 10 monthly installments. Tuition payments are due on or before the 1^st of each month beginning in September. The last payment is due on or before June 1^st. All monthly installments are due on the 1^st of each month. After the 5^th of the month, a late fee of $5 per school day will be added to the account

*Tithing members of Back Bay Christian Assembly will receive an additional 10% discount on tuition in the K-12 program when written proof of tithing is provided. This information is available from the church treasurer.

Birth Certificate

Current Immunization Record

Please also provide previous school transcripts (if available)

Please note that we will request your child’s official transcripts from the school in which he is currently enrolled. After reviewing the transcripts, we will contact you to inform you of your child’s application status.