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1 Springfield Christian Academy A Ministry of Dixie Baptist Church 8585 Dixie Highway, Clarkston, MI Forms not accepted without complete information and payment Registration School Year Family Last Name Street Address City, State, Zip Today s Date Home Phone Father s Name Employer Work Phone Social Security # Cell Phone Pager Mother s Name Employer Work Phone Social Security # Cell Phone Pager If separated or divorced, with whom does the child(ren) live? Student s FULL Name (and last name if different) Social Security Number Birth Date Grade Entering Physical/Medical Conditions (If yes, please specify) In case of emergency and parents can not be contacted, please call: Name Relation Phone Name Relation Phone Name of person(s), other than parents that may pick child(ren) up from school: Physician s Name Phone Hospital Preference Type of Insurance Insurance # Group # Church Attending Pastor s Name Are you a member? School Last Attended Complete Address For Office Use Only: Immunization Records (Each Student) Vision/Hearing Records (K-5 Only) Smart Tuition Form (Each Family)

2 SPRINGFIELD CHRISTIAN ACADEMY Doctrinal Statement We believe the Bible, consisting of the Old and New Testaments, to be the only inspired, inerrant, infallible, and authoritative Word of God. (II Timothy 3:16-17) We believe in the creation of man by the direct act of God (Genesis 1:26-27). We believe in the total depravity of man through the fall of Adam (Genesis 3; Romans 5:12-17). We believe in the deity of our Lord Jesus Christ, in His Virgin birth, in His sinless life, in His miracles, in His vicarious and atoning death through His shed blood, in His bodily resurrection, in His ascension to the right hand of the Father, and His personal return in power and glory. We believe that the new birth is necessary for every person, and the only way to receive eternal life and grace is through faith in Jesus Christ (Ephesians 2:8-9; Acts 16:30-31). We believe in the resurrection of both the saved and the lost; those who are saved unto the resurrection of life, and those who are lost unto the resurrection of damnation. I understand that my child will be taught these doctrines while enrolled as a student at Springfield Christian Academy. Both parents/guardians required signatures: Parent/Guardian Signature: Parent/Guardian Signature: Dated: Dated:

3 Springfield Christian Academy PARENTS STATEMENT OF COOPERATION AND ACCEPTANCE (Please read carefully before signing) 1. We agree to accept the rules, policies, and regulations of SCA on the behalf of our child. 2. We authorize SCA to employ such discipline as it deems wise and expedient in order for our child to adhere to the standards and policies of SCA. 3. We give permission for our child to take part in all school activities, including sports and school-sponsored trips away from the school premises, and we absolve SCA from any liability to us or our child because of any injury at school or during school activities, on or off campus. 4. We agree to meet our financial obligations to SCA and understand that applicable late fees will be assessed to delinquent accounts. We understand that SCA reserves the right to terminate the enrollment of our child should financial accounts become delinquent past 30 days. 5. We recognize that our participation is needed in prayer, service, and special gifts in order to properly share in the burden of training of our child. 6. We agree to uphold and support the high academic standards of SCA by providing a place at home for our child to study and by giving encouragement in the completion of homework and assignments. 7. We understand the standards of SCA do not tolerate profanity, obscenity in word or action, dishonor to God or the Word of God, or disrespect to the personnel employed by SCA. 8. We pledge our loyalty to the goals of SCA and will bring questions and criticisms directly to the administration so that problems may be properly considered by those in authority. We agree that in any situation in which an agreement is not found, we understand that the school administration reserves the right to make any final decisions. 9. We understand that attendance at SCA is a privilege, not a right, and this privilege may be forfeited by any student who does not conform to SCA s standards and regulations. SCA may request the withdrawal of any student at any time who does not fulfill the spirit of specific rules and regulations. 10. SCA has an obligation to its employees and is dependent upon the tuition and fee payments of all families. Tuition is based upon the entire school year and is due at the time each student is accepted and enrolled. Individual payment plans for applicants may be accepted, as specified in the on the current Financial Information sheet. If a student is withdrawn or dismissed from SCA for any reason after acceptance and enrollment, we are responsible for payment of all remaining unpaid tuition and fees. I understand that prepaid tuition and fees are non-refundable. Unpaid tuition or fee balances are subject to collection which shall include costs of collection, including reasonable attorney s fees. 11. We understand that school records, documents, transcripts, and online services are not released until all financial obligations have been met. 12. We surrender any rights that we may have to file a lawsuit against Springfield Christian Academy for any present or future legal claim that we may have involving or affecting the school. Because the Bible commands Christians to settle their disputes privately or within the church, we promise to resolve privately any disputes involving or affecting the school, its employees or its volunteers. We agree to binding arbitration should any legal matter arise. 13. We understand that this is a legally binding agreement, not to be revoked or altered by any party without the written consent of the other parties. Both parents/guardians required signatures: Dated: Dated:

4 Springfield Christian Academy A Ministry of Dixie Baptist Church Student Pledge Each Middle School and High School student attending Springfield Christian Academy is required to sign this Student Pledge, indicating his or her intent to fully cooperate with the standards, rules, and policies of Springfield Christian Academy. Students are held accountable for information contained in the Student\Parent Handbook and are expected to familiarize themselves with its current content. As a student at Springfield Christian Academy, I pledge to: 1. Cooperate and respect those in authority. 2. Strive for excellence in academics, behavior, and in dedication to the principles of the Bible. 3. Abstain from alcohol, tobacco, drugs, and sexual impurity. 4. Refrain from all forms of entertainment that are detrimental to the development of Christian character. In general, I will adhere to the following Biblical principles when choosing entertainment and behavior: Avoid the vulgar Bring into common practice those things that are without value, nasty, base or vile. Avoid the profane Degrading that which has great value. (Example: mocking Biblical values) Encourage Godliness Promote Christ-likeness, personal holiness, selfdiscipline, Biblical family values, spiritual growth, discernment and knowledge. 5. Protect my mind, body and morals by associating with the people of high moral character and avoiding those who do not earnestly seek the will of God for them nor edify others to do so. 6. Willingly obey all school rules, regulations and policies both in letter and spirit, while also avoiding the appearance of evil. 7. Maintain a good, positive influence on fellow students and others by refraining from gossip, grumbling or complaining. 8. Willingly surrender any rights that I may have to file a lawsuit against Springfield Christian Academy for any present or future legal claim that I may have involving or affecting the school. Instead, because the Bible commands Christians to settle their disputes privately or within the church, I further promise to resolve any and all disputes involving or affecting the school, its employees or its volunteers in a private manner. 9. I agree to attend church at least twice a week, either at Dixie Baptist Church, or another church of like faith and practice, approved in advance by the school administration. 10. State that I want to attend and will support Springfield Christian Academy. I understand that breaking this Student Pledge may result in expulsion from the school. STUDENT SIGNATURE: DATE:

5 Springfield Christian Academy A Ministry of Dixie Baptist Church Financial Information School Year Re-Enrollment Registration New Student Registration Before March 31 $75.00 Per Student Before May 26 $ Per Student Before May 26 $ Per Student After May 26 $ Per Student After May 26 $ Per Student Registration fees are due at the time of registration and are non-refundable. Tuition payments for families are billed through SMART TUITION. SMART offers payment options by mail, phone, online, or by automatic bank deductions. New families to SCA must use the automatic monthly debit option for the first year. A one-time convenience fee of $50.00 is due with the first tuition payment. Late tuition payments are assessed a $50.00 late fee by SMART. Annual or semi-annual payments are made directly to Springfield Christian Academy and may be paid by cash or check only. The Annual Plan includes a 5% discount and the Semi-Annual Plan includes a 3% discount if received by July 1, The following monthly plans are available through SMART Tuition: Yearly Tuition Rates Grades Month Payment Plan Payments Due August 1 May 1 12 Month Payment Plan Payments Due July 1 June 1 1 st Child $3, $ Month $ Month 2 nd Child $3, $ Month $ Month 3 rd Child or more $3, $ Month $ Month Semi-Annual (Includes 3% Discount) Payments Due July 1 & December 1 2 payments of $1, payments of $1, payments of $1, Collected Through SMART TUITION SCA Annual (Includes 5% Discount) Payment Due July 1 $3, $3, $3, All other fees are paid directly to Springfield Christian Academy. Failing to meet payment deadline will result in loss of applied discounts. Please see reverse for applicable fees Dixie Highway, Clarkston, MI 48348,

6 Standard Fees: Fees are non-refundable and must be paid by first day of school. Students with unpaid fee accounts may not attend classes until accounts are current. Book Fee: (Grades 1-6, per student) This fee covers the cost of one copy of each workbook and rental for each hardcover book for the year. *Students registering after July 1 must pay book fee at the time of registration. If paid by May 26, 2016: $230.00* If paid after May 26, 2016: $ Elementary Activity Fee: (Grades 1-6 per student) $ This fee covers the cost of MACS membership, MACS Fine Arts group competitions, (MACS individual and small group events billed separately), insurance, Standardized Testing, and admission to all regular season home games. Grades 7-12: Order books through classbook.com Middle School/High School Activity Fee: (Grades 7-12, per student) $ This fee covers the cost of School Camp, MACS membership, MACS Fine Arts Full Club competitions, (MACS individual and small group events billed separately), insurance, standardized testing, and admission to all regular season home games. Club Fee (Grades 7-12, per student) $15.00 This fee covers the cost of purchasing club materials Technology Fee: Covers the use of school network, RenWeb, computer labs and software, Rosetta Stone, and curriculum assessment products. Grades 1-6, per student $40.00 Grades 7-12, per student $65.00 Standard fees paid in full by July 31, 2016 receive a 2% discount. (*Early Elementary book fee excluded) Individual Fees: The following fees are billed at the time of each event: Orientation Fee: (Grades 1-12, per family) $20.00 This fee is waived simply by at least one parent and student attending the Student/Parent Orientation meeting. High School Graduation Fee: (Grade 12 only, billed April 1st) $50.00 This covers the cost of diploma, graduation program, and commencement awards. Athletic Participation: (Per student/per sport, billed at beginning of season) $ Assessed at the beginning of each sport season (fall, winter, and spring). Parents of athletes will be asked to assist with concessions and/or gate during the season of their child s participation. Late Fee: A 5% late fee will be charged on any outstanding school balance each month, not to exceed $ This fee is assessed to any account with Springfield Christian Academy not paid in full by the first of each month. School account late fees are separate from any fees that may be assessed by SMART Tuition. Non-sufficient funds fee: $25.00 This fee will be assessed to any account in the event that there is a check returned for non-sufficient funds. Supervised After-School Study Hall & Supervised Care Supervised After-School Study Hall is available from 3:30 pm until 3:50 pm for children of working families at the rate of $7.00 per child per hour. At 3:50pm, students are transported by school staff to The Children s Ark Development Center for supervised care at the same hourly rate. The Children s Ark closes at 6:00 pm. *SCA accepts MasterCard and Visa credit cards only. Credit card payments are assessed a 2% service fee.

7 Annual Field Trip Release/Emergency Medical Form Springfield Christian Academy Dixie Hwy. Clarkston, MI School Year This form will be on file at the school office for the current school year. An additional Permission to Participate form will be sent home prior to each off-campus trip. I give my permission for, grade, to participate in all sports and school-sponsored trips away from the school premises throughout the current school year. Students will be accompanied by a teacher and will be under adequate supervision. I understand that I will be given, at least 48 hours, notice of all trips away from the school premises. I further understand that I may revoke permission for a specific field trip by written notice hand delivered to the principal more than one day prior to the trip. Although the school desires to provide a safe and enjoyable time for all students, accidents can still happen. I/we understand that there are risks/dangers involved with participation in off-campus trips and their associated activities. In consideration for my child being allowed to participate in this event, I/we assume responsibility for those ordinary and reasonable risks associated with the travel and activities. I/we agree to hold harmless Springfield Christian Academy, its affiliated organizations, employees, agents, and representative, including volunteer and other drivers, from any and all claims arising from my child s participation. This release agreement does not apply to claims intentional (criminal) misconduct or gross negligence by the school, its employees, or volunteers. I such circumstances are proved in a court of law, I/we acknowledge and agree that the school can assume no financial liability beyond its actual liability insurance policy in force. In case of accident, illness, or other emergency, I/we request that the school contact me. If the school cannot reach a parent/guardian after conscientious effort, I/we give permission for school staff to call paramedics or any licensed physician or dentist. If a life-threatening emergency exists, I/we give permission for school staff to immediately call paramedics and then contact me/us as soon as possible thereafter. I/we authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which, in the best judgment of a licensed physician or dentist, is deemed advisable. I/we agree to assume the financial responsibility for expenses incurred as a result of those services being provided. I/we also agree to be financially responsible for emergency medical transportation. Father/Guardian s Signature Date Mother/Guardian s Signature Date Father s name printed Mother s name printed If the child lives with both parents, the release must be signed by both parents/guardians.

8 Volunteer Driver Application Form / School Year We often need help in transporting students on field trips or for sports events. Our school parents have been generous in their assistance. The purpose of this form is to reduce the liability of the school and volunteer drivers by being proactive in our selection of parent drivers. If you are interested in helping with such needs during the school year, please fill out this form and return it (along with copies of your driver s license and your current vehicle insurance card) to the school. A new Volunteer Driver Application Form must be filled out each school year. Section I Volunteer Driver Information Name: Phone number: Driver s License #: Exp. Date Address: Car Model/Yr: (1) (2) Number of working seat belts in car #1 (2) License number for car #1 #2 The school requires volunteer drivers to have a minimum amount of liability insurance. (1) #100,000 liability for bodily injury per person; (2) $300,000 liability per incident for bodily injury for all vehicle occupants; and (3) $50,000 - $100,000 liability for property damage. Amount on this (these) car(s) Car #1 - Insurance Co.: Policy #: $ $ $ Car #2 Insurance Co.: Policy #: $ $ $ Yes No Are you licensed to drive a commercial vehicle? Yes No Have you been in an accident in the last three years? If you answered YES, please describe the accident and its cause on another sheet of paper and attach it to this form. Yes No - Have you been ticketed for moving violations with the last three years? If you answered YES, please describe the infractions on another sheet of paper and attach it to this form. Yes No Have you been convicted for DWI/DUI of alcohol or drugs, or had your license suspended for moving violations, hit and run, eluding an officer, reckless or negligent operation of a vehicle, or driving while under suspension or revocation? [Note; Our school will not be able to use volunteers with a yes answer even if the incident took place before the person became a Christian.] Section II Requirements for Volunteer Drivers I certify that for the school year: I possess a valid (state) driver s license.

9 I will contact my insurance agent to ascertain if there are any liability policy limits or exclusions regarding transporting other students or faculty members on a field trip that might affect my ability to meet the qualifications for a volunteer driver. I will maintain the minimum insurance coverages required by the school for volunteer vehicles for the vehicle(s) listed in Section I and only volunteer to drive when such insurance policies and coverages are in force. I understand that in case of any type of accident, injury, or vehicle damage, that the school s liability insurance policy does not provide primary or direct insurance on my vehicle. The school s insurance will take effect only after my personal auto insurance limits are exhausted. (Note: This is the only coverage that most nonprofit organizations can provide because of the impossibility of their affording or even obtaining primary or direct coverage on the vehicles of volunteer drivers.) I will advise the school of any change in information provided on this form including, but not limited to, involvement in a car accident in which I am cited, any citations for moving violations, nonrenewal of license, termination of license, change of insurance company, change on amounts of insurance coverage, termination of insurance, or change in vehicle. Students riding in my vehicle(s) will be seated and both the front and back seat will be secured with individual working seatbelts. (No double belting of children is permitted.) As required by state law, I will have a child restrain seat for each child under age or under pounds (typically 40 pounds in several states). To my knowledge, my vehicle is in safe operating condition(brakes, tires, etc) I will read and follow the Driver and Chaperone Instructions sheet for the field trip. I will notify school personnel if I no longer wish to drive or if I wish to be removed from the Approved Driver List. Section III Declaration and Signature I affirm that I will carefully transport students under my care, including obeying all traffic laws. The information given on this form is true and correct to the best of my knowledge. Signed: Date Section IV School Administration Approval Approved Disapproved for addition to the school s Approved Driver List. Administrator s Signature: Date