2017-2018 Academic Year

Carney Christian Academy 14861 Denham Road Pride, Louisiana 70770 225-999-3089

APPLICATION FOR ADMISSION

Student Name: ______Nickname: ______

Student’s age as of August 1, 2017 ______Birth date ______

Student resides with:

_____Father _____Mother _____Stepmother _____Stepfather _____Guardian _____Other

Address:

Street City Zip

Home Phone: ______listed unlisted

Father Stepfather Guardian Other Mother Stepmother Guardian Other

Name: ______Name: ______

Home Address (if different from above) Home Address (if different from above) ______

______

Home Phone (if different from above) Home Phone (if different from above) ______

Cell Phone______Cell Phone ______

Employer Employer ______

Employer phone: Employer phone: ______

Sibling age grade current school ______Has applicant ever attended a school or program designed for students who have academic or other needs (such as programs for the gifted, special learning, 504 modifications, etc?) If so please describe:

______

Please check all that apply:

______Testing/counseling by a psychologist, psychiatrist, education consultant, or counselor or any interventions outside of the school setting (educational testing or interventions including but not limited to: occupational therapy, speech and language therapy, learning specialist, mental or emotional distress)

______Currently on or recently completed probation for a juvenile offense.

*****as part of the application process, we require information about any testing or interventions that are taking/have taken place. Failure to disclose this information during the admission process could result in denial of admission or serve as grounds for dismissal of the student from school

I hereby make application for the admission of the above-named child. I verify that all of the information portrayed here is accurate.

Parent or Guardian Date

Carney Christian Academy 14861 Denham Road Pride, Louisiana 70770 225-999-3089

2017-2018 Academic Year

MEDICAL RELEASE AND PERMISSION FORM

Effective Dates: ______to ______

Please print in ink Name: ______Last First Middle

Age: ______Birth date: ______Male_____ Female_____

Address: ______

______City State Zip

Home Telephone: ______

Mother ______Cell ______Work ______

Father ______Cell______Work______

Emergency Contact: ______Phone______

Work______

Medical Insurance Company______

Policy Number ______

Physician ______Office Phone ______

Dentist ______Office Phone ______

Medical History: Please check any categories that apply and explain: Please include any current medication

______Allergies ______current/recurrent illness _____Relevant Medical History

______

Does your child wear glasses or contact lenses? ______

This consent from gives permission to seek whatever medical attention is deemed necessary, and release CARNEY CHRISTIAN ACADEMY, CARNEY CHRISTIAN SERVICES, INC and/or TERRI CARNEY/CHARITY TATE of any liability against personal losses of named child during any and all events.

I/We the undersigned have legal custody of the student named above, a minor, and here by release CARNEY CHRISTIAN ACADEMY, CARNEY CHRISTIAN SERVICES, INC and/or TERRI CARNEY/CHARITY TATE from any and all liability for any injury, loss or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a physician, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician.

In the event treatment is required from a medical physician and/or hospital personnel designed by CARNEY CHRISTIAN ACADEMY, TERRI CARNEY and/or CHARITY TATE, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.

I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider.

Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above.

______Signature of parent or guardian Date