<p> Carney Christian Academy 14861 Denham Road Pride, Louisiana 70770 225-999-3089</p><p>2017-2018 Academic Year</p><p>APPLICATION FOR ADMISSION</p><p>Student Name: ______Nickname: ______</p><p>Student’s age as of August 1, 2017 ______Birth date ______</p><p>Student resides with:</p><p>_____Father _____Mother _____Stepmother _____Stepfather _____Guardian _____Other</p><p>Address:</p><p>Street City Zip</p><p>Home Phone: ______listed unlisted</p><p>Father Stepfather Guardian Other Mother Stepmother Guardian Other</p><p>Name: ______Name: ______</p><p>Home Address (if different from above) Home Address (if different from above) ______</p><p>______</p><p>Home Phone (if different from above) Home Phone (if different from above) ______</p><p>Cell Phone______Cell Phone ______</p><p>Employer Employer ______</p><p>Employer phone: Employer phone: ______</p><p>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:</p><p>______</p><p>Please check all that apply:</p><p>______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) </p><p>______Currently on or recently completed probation for a juvenile offense. </p><p>*****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</p><p>I hereby make application for the admission of the above-named child. I verify that all of the information portrayed here is accurate.</p><p>Parent or Guardian Date</p><p>Carney Christian Academy 14861 Denham Road Pride, Louisiana 70770 225-999-3089</p><p>2017-2018 Academic Year</p><p>MEDICAL RELEASE AND PERMISSION FORM</p><p>Effective Dates: ______to ______</p><p>Please print in ink Name: ______Last First Middle</p><p>Age: ______Birth date: ______Male_____ Female_____</p><p>Address: ______</p><p>______City State Zip</p><p>Home Telephone: ______</p><p>Mother ______Cell ______Work ______</p><p>Father ______Cell______Work______</p><p>Emergency Contact: ______Phone______</p><p>Work______</p><p>Medical Insurance Company______</p><p>Policy Number ______</p><p>Physician ______Office Phone ______</p><p>Dentist ______Office Phone ______</p><p>Medical History: Please check any categories that apply and explain: Please include any current medication</p><p>______Allergies ______current/recurrent illness _____Relevant Medical History</p><p>______</p><p>Does your child wear glasses or contact lenses? ______</p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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.</p><p>______Signature of parent or guardian Date</p>