Warwick River Christian School

252 Lucas Creek Road  Newport News VA 23602 757-877-2941 www. warwickriver.org NEW Student Registration Form: ______(school year)

Please print clearly. Provide all information requested unless it does not apply. 1. Student's full name (first, middle, last):

2. Student's preferred first name or nickname: 3. Student’s sex: _ _ M F

4. Student's date of birth: Month: Day: Year:

5. Name(s)/birthdate(s) of sisters and brothers:

6. For statistical reporting purposes only, please provide the following information concerning this student (select one): African American/Black Asian/Pacific Islander Hispanic/Latino(a) Middle Eastern Multiracial Native American White or Caucasian Other (Please specify)

7. Please mark the class level this student will be entering for the school year: 3-Year-Old Preschool 4-Year-Old Preschool Kindergarten Elementary School Middle School Must be Age 3 by 9/30 Must be Age 4 by 9/30 Age 5 by 9/30 (Age 6 by 9/30 for Grade 1) 2 days a week, AM 3 day Half-day Grade 1 Grade 6 3 days a week, AM 5 day Half-day K5 Grade 2 Grade 4 Grade 7 5 days a week, AM 5 day All-day Grade 3 Grade 5 Grade 8

8. Do you desire Bus Service? Yes No If Yes, Bus Service is needed: AM 3:00 PM If other than home, give address and phone number where bus is to pick up or deliver your child: Pick Up: Home. Other address: Phone: Take Home: Home. Other address: Phone: Please give directions from the nearest major street to the busing address:

9. Parent information. Please list parents or guardians who have responsibility for the child: Father Mother Full name: Full name: Home Phone: _ Home Phone: Cell Phone: Cell Phone: E-mail: E-mail: Address: _ Address: City/State/Zip: City/State/Zip: Employer: Employer: _ Position/Occupation: Position/Occupation: _ Work Phone: Work Phone:

10. Church affiliation: Denomination: Congregation:

11. Emergency contact information. In case the parents/guardians are not available, whom should we contact? Name Relationship to Student Day Phone A. _ B.

12. Payment Plan for Tuition - please check your preference. Plan A - Semester payments (due August 1 and January 2) Plan B - Monthly payments (ten equal payments normally starting August 1 and extending through May 1) The Registration Fee is due with this registration form. The Setup/Supporting Service Fee is due June 1. 13. Please describe how you learned about Warwick River Christian School.

14. Outline your reasons for wanting your child to attend Warwick River Christian School.

15. What are your expectations of WRCS in your child's academic, spiritual, and social development?

16. State what you feel are your responsibilities as a parent in your child's education.

17. What academic difficulties, if any, has your child had in school thus far? Please describe.

18. Has retention in the same grade level ever been recommended for your child? Yes No If yes, describe the circumstances, including any action taken as a result of the recommendation.

19. Has your child been recommended by a previous school for a child study? Yes No If yes, describe the circumstances, including any action taken as a result of the recommendation.

20. Does your child have an Individualized Educational Plan (IEP) or a 504 Plan? Yes No If yes, please attach a copy. If a copy is not available, give a brief summary here.

21. What behavioral difficulties, if any, has your child exhibited in school thus far? Please describe, including the nature of disciplinary action applied.

22. Has your child ever been suspended, dismissed, or expelled from school? Yes No If yes, expand on anything not included in No. 21.

23. Mention anything else that will contribute to the success of your child as a student at WRCS.

MEDICAL INFORMATION:

A. Physician/Pediatrician: Phone:

B. Facts concerning your child's medical history, allergies (including foods), medications being taken, and any physical or emotional impairments to which school personnel should be alerted:

C. If your child becomes ill or injured, in the event that you cannot be notified, may we proceed with first aid and emergency medical care for your child?

Yes No Parent's Signature Date: PUBLICITY PERMISSION: Permission is hereby granted to include student and parent name, address, phone number, and e-mail on a list provided only to our school families unless noted below. Permission is hereby granted for the school to use my child’s name and photo in school publications, publicity pieces, and on the school website unless noted below.

Comments:

STATEMENT OF UNDERSTANDING AND COOPERATION

 I understand that submitting this application does not guarantee my child is enrolled at Warwick River Christian School. It is the first step in the process.

 I agree to support Warwick River Christian School in following the policies stated in the Parent Information Packet or Handbook. If any questions or problems arise, I will bring them to the attention of the proper authority, whether it be teacher, office manager, bookkeeper, principal, or administrator.

Father/Guardian Mother/Guardian Date

Social Security No Social Security No

For Office Use Only  Registration Fee received.  Medical Information signed.  Statement of Cooperation signed.  Birth Certificate on file.  Virginia Health Form on file.  Evidence of MMR vaccination (Kindergarten 5) on file.  Evidence of Hepatitis B & Tdap vaccinations (Grade 6) on file.  Interview with the Principal.