Registration Packet 2012 2013 by m7mZ5Z8

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									                                         Community Christian School
                                      2012 - 2013 Registration Instructions

                                     PLEASE KEEP THIS PAGE FOR YOUR INFORMATION

   Registration packets must be submitted in person by a student’s parent or legal guardian. Only complete registration packets
will be accepted; therefore the parent/guardian must remain present as the packet is being processed. Incomplete packets will be
returned to the parent/guardian for resubmission after the needed documents or information is added.
   Your child’s name will be placed on a waiting list if his/her class has reached full enrollment at the time your packet is received.
Community Christian School reserves the right to refuse admission of a student for academic reasons or for behavioral tendencies that we
believe would not be in the best interest of our student body.

Re-enrollment for returning students opens on Monday, March 5, 2012
Registration packets will be accepted only between the hours of 8:30 - 9:30 am and from 2:00 - 3:30 pm during the week of Monday,
March 5 through Friday, March 9.

Open enrollment for the public opens on Tuesday, March 27, 2012
Registration packets will be accepted only between the hours of 8:30 - 9:30 am and from 2:00 - 3:30 pm during the week of Tuesday,
March 27 through Tuesday, April 3.

After these initial periods of enrollment, packets will be accepted in the school office throughout the school day as time
permits; but please be aware that you will experience more of a wait time if you come during the rush as the school day starts or ends
and at lunchtime.

    REGISTRATION REQUIREMENTS FOR ALL ENROLLMENTS;

             a)   Complete all registration forms that are included in this packet.
             b)   * Documentation of Student’s Physical Exam (Yellow Form DH3040)
             c)   Student’s Current Immunization Record (Blue Form 680S), must be signed by a physician
             d)   Legal copy of custody agreement, if parents are divorced or separated
             e)   Copy of parent / guardian driver’s license (for Field Trip purposes)
             f)   Copy of current auto insurance card (for Field Trip purposes)
             g)   Payment of Registration Processing Fee

             * Re-enrollees must have had a physical exam within two years of the school start date.
             * New enrollees must have had a physical exam within one year of the school start date.
                              The school start date is August 14, 2012.

    ADDITIONAL REGISTRATON REQUIREMENTS FOR NEW ENROLLMENTS:

             h)   Student’s Birth Certificate - Copy of the Original
             i)   Student’s parent must sign a “School Records Release Form,” authorizing the student’s current school to transfer
                  their records to Community Christian School. Forms are available in the school office.
                                                                                                                st        th
             j)   Students are required to take a placement test prior to being considered for acceptance into 1 through 8 grades.
                  Placement tests are conducted only following receipt of a completed registration packet accompanied by the
                  Registration Processing Fee.



    FEES -- ALL FEES ARE NON-REFUNDABLE
Registration Processing Fee         All other fees                 Books                    Activity/Supply                K5
    Due when packet is                                                                                                 Graduation
         submitted                  are due on or               $85 - K3                   $150 - K3, K4, K5
                                    before 12:00               $120 - K4                                                   $45
                                                                                                     st    th
   $75.00 through May 10               noon on                 $140 - K5                    $125 - 1 – 8
                                                                       st
                                                               $250 - 1 - 8th
    $125.00 after May 10            July 1, 2012.
                                                                             st
                                   Your child’s spot may be forfeited if July 1 fees are received after the grace period, which ends on
                                          th
                                   July 10 at 12:00 noon.

    TUITION -- $2,500 per year. A 10-month pay plan is available; $250 per month, August through May.

                                        Please make checks payable to Community Christian School.
                                       345 SE Palmetto Avenue  Keystone Heights  Florida  32656
                                              Phone: (352) 473-6600   Fax (352) 473-5103
                                                   www.communitychristianschoolofkh.com
                                  Community Christian School
                               2012 - 2013 Registration Agreement
                                           Parent Copy
Financial Policies

       1.    Registration processing fees, once submitted with a completed registration packet, are not
             refundable.
                                                  st
       2.    All other fees are due by July 1 and are not refundable. Failure to pay these fees by noon on July
                 th
             10 may result in the forfeiture of the student’s seat in class.
       3.    Tuition may be paid on a 10-month installment payment plan. One-tenth of the annual tuition is due
             on a monthly basis during the school year; payable the first day of each month, August – May.
                                                                                                     th
       4.    A $20.00 late fee (per student) may be assessed on accounts not paid in full by the 10 of each
             month.
       5.    A $30 fee will be assessed for any check returned for any reason. If more than three returned
             checks are received in one academic year, checks will no longer be accepted -- payments will be
             required in cash or by money order.
       6.    Should an account become delinquent, a statement or letter will be sent to the parent/guardian via the
             student’s Thursday Folder; in cases of significant unresolved delinquency a student may be
             suspended from class.
       7.    Should any collection fees, attorney fees or court costs be incurred by Community Christian School,
             resulting from collection attempts on a delinquent account, they will be added to the existing balance of
             such account.
       8.    Accounts must be paid in full at the end of the school year or upon withdrawal of a student in order for
             report cards or student records to be released.
       9.    Tuition will be pro-rated for students who are enrolled after the school year begins.
      10.    No portion of any installment payment for tuition will be refunded for students who are withdrawn once
             classes begin. Meaning, if a student attends even one day of classes in any given month, the tuition
             billed in that month is due in full.

  Other Conditions / Expectations

        1.   School Administration reserves the right to refuse admission of a student for academic reasons or
             for behavioral tendencies that we believe would not be in the best interest of our student body.
        2.   The success of a student’s education is dependent on open and on-going communication between
             parents/guardians and the teaching and administrative staff of Community Christian School.
        3.   Parents/guardians are expected to read the School Handbook and be knowledgeable of and agree to
             follow and support all school policies.
        4.   Parents/guardians are expected to take appropriate action regarding all academic or disciplinary
             notices sent home with their child and to confer with school personnel over any concerns arising from
             these. In addition to mid-quarter reports and report cards, notices sent home with a student may
             include disciplinary referrals or other forms of information.
        5.   Parents/guardians are expected to attend school-initiated conferences with school administrators or
             teachers.
        6.   Parents/guardians are expected to keep abreast of school happenings by reading the Eagle’s Eye
             Newsletter and other bulletins, publications or notices sent home via the “Thursday Folder.”
        7.   Parents/guardians are expected to attend Orientation at the beginning of the school year and school
             programs throughout the school year.
        8.   School Administration will have full responsibility for placing each student in the proper class/grade.
        9.   School Administration reserves the right to dismiss any student who does not respect its spiritual
             standards or who does not cooperate in the educational process.
       10.   A parent or guardian’s failure to provide complete and accurate details about a student’s prior
             suspension, expulsion or criminal conviction is sufficient cause for the student’s dismissal from school.

My signature below is acknowledgement that I have read and understand the financial policies of Community
Christian School as described above. I have also read, understand and agree to abide by the other conditions and
expectations stated above.

If parents/guardians are legally married, both parties must sign each page of the registration packet.


Father/Guardian Signature                                                                              Date


Mother/Guardian Signature                                                                              Date
                                  Community Christian School
                               2012 - 2013 Registration Agreement
                                           Office Copy
Financial Policies

        1.    Registration processing fees, once submitted with a completed registration packet, are not
              refundable.
                                                   st
        2.    All other fees are due by July 1 and are not refundable. Failure to pay these fees by noon on July
                  th
              10 may result in the forfeiture of the student’s seat in class.
        3.    Tuition may be paid on a 10-month installment payment plan. One-tenth of the annual tuition is due
              on a monthly basis during the school year; payable the first day of each month, August – May.
                                                                                                      th
        4.    A $20.00 late fee (per student) may be assessed on accounts not paid in full by the 10 of each
              month.
        5.    A $30 fee will be assessed for any check returned for any reason. If more than three returned
              checks are received in one academic year, checks will no longer be accepted -- payments will be
              required in cash or by money order.
        6.    Should an account become delinquent, a statement or letter will be sent to the parent/guardian via the
              student’s Thursday Folder; in cases of significant unresolved delinquency a student may be
              suspended from class.
        7.    Should any collection fees, attorney fees or court costs be incurred by Community Christian School,
              resulting from collection attempts on a delinquent account, they will be added to the existing balance of
              such account.
        8.    Accounts must be paid in full at the end of the school year or upon withdrawal of a student in order for
              report cards or student records to be released.
        9.    Tuition will be pro-rated for students who are enrolled after the school year begins.
       10.    No portion of any installment payment for tuition will be refunded for students who are withdrawn once
              classes begin. Meaning, if a student attends even one day of classes in any given month, the tuition
              billed in that month is due in full.

 Other Conditions / Expectations

         1.    School Administration reserves the right to refuse admission of a student for academic reasons or
               for behavioral tendencies that we believe would not be in the best interest of our student body.
         2.    The success of a student’s education is dependent on open and on-going communication between
               parents/guardians and the teaching and administrative staff of Community Christian School.
         3.    Parents/guardians are expected to read the School Handbook and be knowledgeable of and agree to
               follow and support all school policies.
         4.    Parents/guardians are expected to take appropriate action regarding all academic or disciplinary
               notices sent home with their child and to confer with school personnel over any concerns arising from
               these. In addition to mid-quarter reports and report cards, notices sent home with a student may
               include disciplinary referrals or other forms of information.
         5.    Parents/guardians are expected to attend school-initiated conferences with school administrators or
               teachers.
         6.    Parents/guardians are expected to keep abreast of school happenings by reading the Eagle’s Eye
               Newsletter and other bulletins, publications or notices sent home via the “Thursday Folder.”
         7.    Parents/guardians are expected to attend Orientation at the beginning of the school year and school
               programs throughout the school year.
         8.    School Administration will have full responsibility for placing each student in the proper class/grade.
         9.    School Administration reserves the right to dismiss any student who does not respect its spiritual
               standards or who does not cooperate in the educational process.
        10.    A parent or guardian’s failure to provide complete and accurate details about a student’s prior
               suspension, expulsion or criminal conviction is sufficient cause for the student’s dismissal from school.

 My signature below is acknowledgement that I have read and understand the financial policies of Community
 Christian School as described above. I have also read, understand and agree to abide by the other conditions and
 expectations stated above.

 If parents/guardians are legally married, both parties must sign each page of the registration packet.


 Father/Guardian Signature                                                                              Date


 Mother/Guardian Signature                                                                              Date
                                          Community Christian School
                                       2012 - 2013 Student Enrollment Form
                                                    Office Copy

     Where did you get this Registration Packet?                                    Please keep all information updated
     ______ Downloaded from the website                                             throughout the school year.
     ______ Picked it up from the school




    Student Name: ___________________________________________________________                        M or F      Grade: ___________
                        Last                          First                                 MI     Circle One

    Preferred Name: _____________________________________                  Phone: __________________________________________

    Date of Birth: ________________________________________                Social Security #: __________________________________

    Home Address: __________________________________________________________________________________________

    Mailing Address (if different and/or P.O. Box): ___________________________________________________________________

    Previous School Attended: __________________________________________________________________________________

    Has your child ever been suspended or expelled from any other school or convicted of any criminal offense? ____ No ____ Yes
    If yes, give details: ________________________________________________________________________________________

    _______________________________________________________________________________________________________

    Church Affiliation: _________________________________________________________________________________________

    Reason(s) for Selecting School: ______________________________________________________________________________




Student Pick-Up and Emergency Contacts (other than primary parent info):

Contact 1: ____________________________________________________            Contact 2:___________________________________________________
                     Last                  First           MI                                  Last                   First          MI

Relationship to Student: __________________________________________        Relationship to Student: ________________________________________


Home: _________________________ Work: __________________________           Home: _______________________ Work: _________________________


Cell: ___________________________                                          Cell: _________________________


Contact 3: ____________________________________________________            Contact 4:____________________________________________________
                     Last                  First           MI                                  Last                   First          MI

Relationship to Student: __________________________________________        Relationship to Student: ________________________________________


Home: _________________________ Work: __________________________           Home: _______________________ Work: _________________________

Cell: ___________________________                                          Cell: _________________________




Father/Guardian Signature                                                                                                Date


Mother/Guardian Signature                                                                                                Date
                                      Community Christian School
                                2012 - 2013 Parent/Guardian Information
                                              Office Copy

        Student Name: _______________________________________________________________________________              Race: __________
                          Last                            First                       Middle

        Parent/Guardian Marital Status: ____ Married ____ Separated ____ Divorced ____ Widowed ____ Single ____ Remarried


        Parent/Guardian Name: __________________________________________________________________________________________
                                  Last                                    First                                    MI

        Who has primary custody of student? _____________________________       Relationship to Student: ______________________________

        Address: ________________________________________________________________________________________________________
                          Lives with Student                Has Custody of Student

        Home Phone: ________________________________________ Work Phone: ________________________________________________

        Cell Phone: __________________________________________ Email Address: ______________________________________________

        Employer’s Name: _____________________________________ Position: ___________________________________________________

        Work Address: ___________________________________________________________________________________________________


        Parent/Guardian Name: ___________________________________________________________________________________________
                                  Last                                    First                                    MI

        Relationship to Student: _________________________________________

        Address: ________________________________________________________________________________________________________
                   Same as Above                Lives with Student                Has Custody of Student

        Home Phone: ___________________________________________Work Phone: _______________________________________________

        Cell Phone: ____________________________________________ Email Address: _____________________________________________

        Employer’s Name: _______________________________________ Position: __________________________________________________

        Work Address: ___________________________________________________________________________________________________


        Person(s) Responsible for Tuition:
        ____ Mother                ____ Father                 ____ Other (please fill out section below)

        Name: _________________________________________________________________________________________________________
                Last                                             First                                   MI

        Address: _______________________________________________________________________________________________________

        Phone: __________________________________________ Relationship to Student: __________________________________________

   Name(s) of Brothers and Sisters/Relatives Attending CCS:       Name(s) of person(s) living in student’s household (other than CCS students):

   Name (Last, First, Middle)             M or F   Grade            Name                                     Relationship

   _____________________________ _____              _____           ____________________________________________________

   _____________________________ _____              _____           ____________________________________________________

   _____________________________ _____              _____           ____________________________________________________

   _____________________________ _____              _____           ____________________________________________________

   _____________________________ _____              _____           ____________________________________________________



Father/Guardian Signature                                                                                                   Date


Mother/Guardian Signature                                                                                                   Date
                                Community Christian School
                              2012 - 2013 Discipline Procedures



We desire that, as children are disciplined in our school, our criteria will be met and communicated in
a loving way to the child. We also strive to maintain clear lines of communication with the parents to
prevent serious problems from developing.

If parents have questions about a policy or disciplinary action, they should follow this procedure.
                 1. Give the staff the benefit of the doubt – realizing that your child’s reporting may
                     be emotionally biased and may not include all the information.
                 2. Realize that the school staff has reasons for rules and that we attempt to
                     enforce them without partiality.
                 3. Call the school to get the facts straight and to offer your support.
                 4. If you have a question concerning a situation in the classroom, please
                    contact the teacher first. Then if there is no resolution, please contact
                    administration. All contacts should be courteous and respectful.

When a student interferes with the learning process of other students, it becomes necessary for the
teacher to find effective ways to correct that student. These may be in-class discipline,
student-teacher conferences or parent-teacher conferences. If the student continues to disturb
others, the teacher will refer that student to the principal’s office for disciplinary action.

The student will receive a discipline referral to take home for parents to sign and return. This is
the student’s responsibility, and he/she has one day to return the referral. If it is not returned,
a copy may be mailed to the parents to be signed and returned.

Disciplinary action will vary depending upon the severity of the offense and may include the following.

    Warning or utilization of teacher’s assertive discipline plan
    Parent conferences with teacher and/or principal
    Loss of privileges
    Detention table and work duty at recess.
    In-school suspension (ISS): The student will be assigned to an isolated silent study area for
     the day.
    Out-of-school suspension: Any MAJOR violation of the school rules may result in a student
     being suspended from school for a period of time up to ten days. Parents may be called to
     pick up their child. Students on suspension may not be on campus or at school-sponsored
     activities or field trips.
    Expulsion: A student may be recommended for expulsion from Community Christian School.
     This is the removal of the right of a student to attend our school for the remainder of the
     academic year. Any unused tuition is non-refundable.




Father/Guardian Signature                                                                      Date


Mother/Guardian Signature                                                                      Date
                                                  Community Christian School
                                                 2012 - 2013 Internet Usage Form



Student Name: _____________________________________________________ Grade: ______________________

Execution of this agreement will authorize your child to access the Internet at school as part of his/her class instruction. An agreement is required for
each child. Please read the rules for computer and Internet use that are outlined below. If you choose to grant permission for your child
to have Internet privileges, please review the rules with your child and then both you and your child must sign this agreement.

Rules for Internet Usage
1)     Both parents and student must execute this agreement.
2)     Respect for computer and network equipment is a condition for its use.
3)     Students must notify the teacher immediately of any disturbing and/or inappropriate material they may encounter on
4)     the web.
5)     Students are not to give out personal information such as name, address, telephone number, etc., to anyone via
6)     the Internet.
7)     Instant messaging and accessing chat rooms is strictly prohibited.
8)     Our computer network is designed for education and business use only; therefore, any games that access the
       Internet are not permitted. In addition, downloading or installing any programs from the Internet or otherwise are strictly prohibited.

Violation of any of these rules may result in forfeiture of permission to use the Internet from school. Additional disciplinary action may be taken as well.



We (I), _______________________________, give our (my) permission for the above named student to access the Internet
via the school’s equipment and network. We (I) recognize it is impossible for Community Christian School to restrict access
to all controversial materials, and we (I) will not hold the faculty responsible for materials acquired on the network.




  Father/Guardian Signature                                                                                                                 Date


  Mother/Guardian Signature                                                                                                                 Date


I, ___________________________________, promise to obey all the rules listed above regarding computer and network equipment and Internet
usage at school.




  Student Signature                                                                                                                         Date



                                                  Community Christian School
                                                 2012 - 2013 Media Release Form

Student Name: _____________________________________________ Grade: _____________________



We (I), ________________________________ parent(s)/guardian(s) of____________________________,
give our (my) permission for Community Christian School to use photographs of my child to illustrate the educational and/or recreational
activities of CCS in communications such as, but not limited to: the yearbook, Eagle’s Eye Newsletter, church newsletters, brochures,
local media, etc.



Father/Guardian Signature                                                                                                                Date


Mother/Guardian Signature                                                                                                                Date

If you do not wish to allow your child’s picture to be used you will need to ask a CCS office staff member to provide you with the Denial of
Photo Release Form. It must be completed and returned to the school office before enrollment is complete.
                                          Community Christian School
                                       2012 - 2013 Student Enrollment Form
                                                   Teacher Copy
                Please keep all information updated throughout the school year.

    Student Name: ___________________________________________________________                        M or F      Grade: ___________
                       Last                           First                                MI      Circle One

    Preferred Name: _____________________________________                           Phone: ___________________________________

    Date of Birth: ________________________________________

    Home Address: __________________________________________________________________________________________

    Mailing Address (if different and/or P.O. Box): ___________________________________________________________________

    Previous School Attended: __________________________________________________________________________________

    Has your child ever been suspended or expelled from any other school or convicted of any criminal offense? ____ No ____ Yes
    If yes, give details: ________________________________________________________________________________________

    _______________________________________________________________________________________________________

    Church Affiliation: _________________________________________________________________________________________

    Reason(s) for Selecting School: ______________________________________________________________________________



Student Pick-Up and Emergency Contacts (other than primary parent info):


Contact 1: _____________________________________________________           Contact 2:___________________________________________________
                     Last                  First           MI                                 Last                   First          MI

Relationship to Student: __________________________________________        Relationship to Student: ________________________________________


Home: _________________________ Work: __________________________           Home: _______________________ Work: _________________________


Cell: ___________________________                                          Cell: __________________________


Contact 3: _____________________________________________________           Contact 4:___________________________________________________
                     Last                  First           MI                                 Last                   First           MI

Relationship to Student: __________________________________________        Relationship to Student: ________________________________________


Home: _________________________ Work: __________________________           Home: _______________________ Work: _________________________

Cell: ___________________________                                          Cell: __________________________




Father/Guardian Signature                                                                                                Date


Mother/Guardian Signature                                                                                                Date
                                         Community Christian School
                                   2012 - 2013 Parent/Guardian Information
                                                Teacher Copy


        Student Name: __________________________________________________________________________________________________
                          Last                                    First                                    MI

        Parent/Guardian Marital Status: ____ Married ____ Separated ____ Divorced ____ Widowed ____ Single ____ Remarried

        Who has primary custody of student? ___________________________


        Parent/Guardian Name: __________________________________________________________________________________________
                               Last                                       First                            MI

        Relationship to Student: ________________________________

        Address: ________________________________________________________________________________________________________
                          Lives with Student                Has Custody of Student

        Home Phone: ____________________________________________ Work Phone: ____________________________________________

        Cell Phone: ______________________________________________ Email Address: __________________________________________

        Employer’s Name: ________________________________________________________________________________________________

        Position: ________________________________________________________________________________________________________

        Work Address: ___________________________________________________________________________________________________


        Parent/Guardian Name: ___________________________________________________________________________________________
                                Last                                      First                            MI

        Relationship to Student: _________________________________________

        Address: _______________________________________________________________________________________________________
                          Same as Above             Lives with Student                Has Custody of Student

        Home Phone: ___________________________________________ Work Phone: _____________________________________________

        Cell Phone: _____________________________________________ Email Address: ___________________________________________

        Employer’s Name: ________________________________________________________________________________________________

        Position: ________________________________________________________________________________________________________

        Work Address: ___________________________________________________________________________________________________



   Name(s) of Brothers and Sisters/Relatives Attending CCS:       Name(s) of person(s) living in student’s household (other than CCS students):

   Name (Last, First, Middle)             M or F   Grade            Name                                               Relationship

   _____________________________ _____              _____           ____________________________________________________

   _____________________________ _____              _____           ____________________________________________________

   _____________________________ _____              _____           ____________________________________________________

   _____________________________ _____              _____           ____________________________________________________

   _____________________________           _____    _____           ____________________________________________________




Father/Guardian Signature                                                                                                   Date


Mother/Guardian Signature                                                                                                   Date
                                    Community Christian School
                                2012 - 2013 Student Health Information
                                            Teacher Copy


Please Print

Student Name: __________________________________________________ Grade: __________________

Parent/Guardian Name: ____________________________________________________________________

Date of Birth: _____________________________________________________________________________



                                               GENERAL INFORMATION

 Allergies:

 ____ Bee Sting    ____ Food ____ Medication ____ Other        If other, list ____________________________

 Please explain reaction(s):
 _______________________________________________________________________________________

 _______________________________________________________________________________________

 Chronic Health Problems/Disabilities:  No Yes If yes, please explain:

 _______________________________________________________________________________________

 Are there any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?________

 If yes, please explain: _____________________________________________________________________

 Activity Restrictions: ______________________________________________________________________

 Regular Medications: _____________________________________________________________________




                                             PHYSICIANS INFORMATION

Name of Physician: __________________________________________ Phone: __________________________

Address: ____________________________________ City: _______________________ Zip: ________________




Father/Guardian Signature                                                                                 Date


Mother/Guardian Signature                                                                                 Date
                                     Community Christian School
                                 2012 - 2013 Student Health Information
                                              Office Copy

Please Print

Student Name: _________________________________________________________ Grade: __________________

Parent/Guardian Name: ___________________________________________________________________________

Date of Birth: ___________________________________________________________________________________



                                               GENERAL INFORMATION

 Allergies:

 ____ Bee Sting    ____ Food ____ Medication ____ Other        If other, list ____________________________

 Please explain reaction(s):
 _______________________________________________________________________________________

 _______________________________________________________________________________________

 Chronic Health Problems/Disabilities:  No Yes If yes, please explain:

 _______________________________________________________________________________________

 Are there any problems with vision, hearing or speech (glasses, contacts, ear tubes, hearing aids)?________

 If yes, please explain: _____________________________________________________________________

 Activity Restrictions: ______________________________________________________________________

 Regular Medications: _____________________________________________________________________




                                             PHYSICIANS INFORMATION

Name of Physician: __________________________________________ Phone: __________________________

Address: ____________________________________ City: _______________________ Zip: ________________




Father/Guardian Signature                                                                                 Date


Mother/Guardian Signature                                                                                 Date
                                     Community Christian School
                            2012 - 2013 Emergency Medical Authorization


Purpose-to enable parents and guardians to authorize the provisions of emergency treatment for children who
become ill or injured while under school authority, when parents cannot be reached.

Student Name: _______________________________________________________ Grade: ________________

Parent/Guardian Name: _______________________________________________________________________

Address: ___________________________________________________________________________________

Home: __________________________ Work: _________________________ Cell: _______________________

Parent/Guardian Name: _______________________________________________________________________

Home: __________________________ Work: _________________________ Cell: _______________________

#1 Emergency Contact Name: ______________________________________ Phone: ______________________

#2 Emergency Contact Name: ______________________________________ Phone: ______________________



                   PART 1 OR 2 MUST BE READ AND SIGNED
           TO CONSENT – I DO NOT GIVE MY CONSENT FOR
Part 1 – REFUSAL
EMERGENCY MEDICAL TREATMENT FOR MY CHILD.

Father/Guardian Signature                                                                        Date


Mother/Guardian Signature                                                                        Date




Part 2- To Grant Consent – I hereby give consent for the following medical care:
           a) Administration of any treatment deemed necessary by the physician, dentist or optometrist
              designated on the Student Health Information Form. In the event the designated practitioner is not
              available, then administration of any treatment deemed necessary by any other licensed physician,
              dentist or optometrist; or
           b) The transfer of my child to any hospital reasonably close. This authorization does not cover
              major surgery unless the medical opinions of two concurring licensed physicians, dentists or
              optometrists are obtained before surgery is performed.

I DO give my consent for emergency medical treatment for my child.



Father/Guardian Signature                                                                        Date


Mother/Guardian Signature                                                                        Date
                                     Community Christian School
                            2012 - 2013 Field Trip Driver Information Form


This form must be filled out COMPLETELY EACH SCHOOL YEAR and kept on file in the office, even if you plan on driving
only your child on field trips. Only one form is needed per family. Please list all children on one form. A photocopy of the
driver’s license and auto insurance card of the person who will be attending field trips must be supplied. The office will provide
copy services if needed.


Student Name: ________________________________________________ Grade: _________________

Student Name: ________________________________________________ Grade: __________________

Student Name: ________________________________________________ Grade: __________________

Student Name: ________________________________________________ Grade: __________________



Parent/Guardian Name: __________________________________________________________________

                            __________________________________________________________________


Name of Insurance Company: ______________________________________________________________

Name of Insuring Agent: ___________________________________________________________________

                     Vehicle # 1                         Vehicle # 2

Year of Vehicle: ______________                          ______________

Make of Vehicle: ______________                          ______________

Model of Vehicle: ______________                         ______________

Tag # of Vehicle: _______________                        ______________


Has your Driver’s License ever been suspended or revoked? No  Yes If yes, please explain:

_________________________________________________________________________________________

Relative(s) designated to act on my behalf on field trips that require parental attendance:

Name: ______________________________________________________ Relationship: _______________

Name: ______________________________________________________ Relationship: _______________




Father/Guardian Signature                                                                                     Date


Mother/Guardian Signature                                                                                     Date
                          CCS Activity Fee
                           School T-Shirt

Student Name: __________________

Grade: __________

CHOOSE EITHER ONE NAVY OR ONE
          GREY ONLY!!!
Navy
Youth
        Youth    Youth     Youth
Extra                               Adult    Adult   Adult   Adult   Adult
        Small   Medium     Large
Small                               Small   Medium   Large    XL     XXL
        (6-8)   (10-12)   (14-16)
(2-4)




Grey
Youth
        Youth    Youth     Youth
Extra                               Adult    Adult   Adult   Adult   Adult
        Small   Medium     Large
Small                               Small   Medium   Large    XL     XXL
        (6-8)   (10-12)   (14-16)
(2-4)

								
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