**Must
be provided.
Student’s
Name _______________________________________________
**
**Address: ________________________________________________________________________________________
Street
Address City State Zip
Reason for leaving:
__________________________________________________________________________________
How did you hear about
**Has the student experienced any problems in relation to drugs, alcohol, smoking, behavior, and school expulsion, etc.? Not disclosing information may result in expulsion). ______ **If YES, please explain: ____________________________________ ___________________________________________________________________________________________________________
SPECIAL HEALTH
OR EDUCATION REQUIREMENTS: (**if
applicable)
**Special Education Needs (reading, speech, gifted,
SLD, LD, ADHD, etc.):
___________________________________
Specialist
involved:
______________________________________ Phone:
______________________________
**Physical Handicaps or Limitations (glasses,
scoliosis, hearing, etc.): ________________________________________
Doctor
involved:
________________________________________
Phone:
_____________________________
Dismissal
from P.E.: ______________________ (YES
requires a note from the Doctor)
**Emotional or Psychological Needs (past or present
treatment):
_____________________________________________
Psychiatrist/Psychologist/Therapist
involved: _________________ Phone: ______________________________
**Special Medications (allergies, asthma,
etc.): ___________________________________________________________
Doctor
involved:
________________________________________
Phone:
_____________________________
Dismissal
from P.E.: ______________________ (YES
requires a note from the Doctor)
**List Medical conditions (allergic reaction)_____________________________________________________________
SPECIAL
STUDENT INTEREST (i.e. Music, Art, Student Council, Yearbook):
_______________________________
__________________________________________________________________________________________________
SPECIAL PARENT INTEREST (i.e. Cafeteria Volunteer, PTF Officer, Fundraising, Library Services, Events Coordinator): ______
____________________________________________________________________________________________________________
We, the undersigned, agree to
fulfill all financial obligations and agree to adhere to the policies and
regulations required by
1. Tuition and miscellaneous fees in arrears will be assessed a $20.00 late charge per month until paid in full.
2. Enrollment or re-enrollment is contingent upon being current with account payments.
3. A student will not be permitted to participate in extracurricular activities for which an additional charge is required if the school account is overdue.
We understand that in the event of withdrawal by the student, or dismissal by the school, the following guidelines shall be in effect:
1. All fees are non-refundable.
2.
All books (hardbound) remain the property of
3. Tuition shall be charged through the end of the month in which the student is enrolled. (A student is enrolled until a formal withdrawal form is completed). If a student is withdrawn on or after the first of the month, tuition will be charged for that month.
4. Tuition and fees in arrears must be paid before diplomas, records, or transcripts are issued. All requests for transcripts will be denied until tuition and fees are paid in full.
We agree that the student may participate in all school
activities and school sponsored trips away from campus unless the school
receives written notice to the contrary,
We recognize that
PARENT/GUARDIAN SIGNATURE: _____________________________________________ DATE: ____________________
PARENT/GUARDIAN SIGNATURE: _____________________________________________ DATE: ____________________
Rev. 2/03