Christian Academy of the Cumberlands APPLICATION FOR ADMISSION

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1 Christian Academy of the Cumberlands APPLICATION FOR ADMISSION APPLYING FOR: GRADE FOR SCHOOL YEAR - Note: A non-refundable fee is due with this application. This earnest payment, along with your child s application, is required to begin the application process of your child. The receipt of these items, however, does not guarantee enrollment for your child. After receiving your child s past records, transcripts, and conducting a family interview, the admission committee will send you a letter to inform you if your child has been accepted. If the child is not accepted, the school will refund the application fee at that time. Names of Children Applying For Admission. Please begin with the oldest child to the youngest. Please use your children s full legal names. Full Legal Name Date of Birth Sex Grade Entering Family Information: Street Address City State Zip Phone Father s Name Street Address City State Zip Phone Father s Employer Phone Mother s Name Street Address (if different than student) City State Zip Phone

2 Mother s Employer Phone Family s Church Pastor Family s Preferred Address If the child s parents are not married, please give the name and address of the non-custodial parent on a separate sheet of paper and indicate whether the non-custodial parent should receive information about the child s progress. Also include information regarding living arrangements for the child and who will have responsibility for payment of tuition. Student Information Please list all of the schools your child has previously attended beginning with the most recent. Please include the Full address of each school. If more space is needed, please provide the information on a separate sheet of paper. Child School Name School Address Phone Number Dates: From/To Grade Completed Christian Academy of the Cumberlands is not staffed to teach children with significant learning disabilities or behavioral issues. We would appreciate your assistance in answering the following questions as candidly as possible. (If more than one child is applying, please note to which child you are referring.) Further elaboration on your answers will take place during the family interview. 1. Does your child have any special learning needs (ADD, ADHD, dyslexia, etc.) that would require regular or special attention in a traditional classroom setting? If yes, please explain: 2. Has your child ever been referred for testing or placed in a special program? If yes, please explain 3. Has your child ever seen or been referred to a counselor/doctor/psychiatrist for any type of social, behavioral, emotional, or mental issue? If yes, briefly state the nature of issue:

3 4. Has your child ever taken medication for a learning or behavioral issue? If yes explain 5. Has your child ever experienced any disciplinary problems at a previous school? (i.e. Has a teacher or administrator EVER contacted you regarding your child s behavior?) 6. Has your child ever repeated a grade for any reason? If yes, which grade? 7. Has your child ever been expelled from a school? 8. Please describe any physical disabilities (heart, hearing difficulties, speech impediments, asthma, etc.) and any serious illnesses, diseases, injuries, or hospitalizations. Christian Academy of the Cumberlands admits students of any race, color, national and ethnic origin to all rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national, and ethnic origin in administration of its educational policies, admissions policies, scholarship programs, athletic programs, and other school administered programs and activities. 4. Education Goals and Expectations 1. Have you read the Christian Academy of the Cumberlands Student/Parent Handbook? Are there any points of philosophy or policy which are inconsistent with your goals for the family? If yes please explain 2. Why do you want your child to attend Christian Academy of the Cumberlands?

4 3. How do you think parents should participate in the education of their children? TO MAKE THIS APPLICATION COMPLETE, PLEASE INCLUDE THE FOLLOWING: 1. Registration Fee 2. A Copy of report cards from the most recent grading term for each child that is applying 3. A Copy of the Transcript Request Letter with a parent s signature Your application will not be processed until ALL of the above documents are received. Thank you. My signature below herein evidences that the information in this application is correct to the best of my understanding. I also state that I have read the Christian Academy of the Cumberland s Statement of Faith, that I understand that it constitutes the doctrinal beliefs of the school, and that I agree to have my children taught in accordance with it. My signature below also evidences that I have read the current Student/Parent Handbook and, if my child is admitted to Christian Academy of the Cumberlands, agree to abide by the policies of the school as stated therein. Father s Signature Date Mother s Signature Date Christian Academy of the Cumberlands Admissions Check List Parents, please use this form to make sure that your admissions process is as swift as possible. 1. Application for Admission 9. Student Commitment 2. Immunization Record (state prescribed form) 10. Request for Records 3. Birth Certificate (photo copy) 11. Medical Release and Emergency Info 4. Medication Permission (if needed) 12. Carpool Form(if needed) 5. Media Release 13. Registration Fee 6. Discipline Agreement 14. Free/Reduced Lunch App(if needed) 7. Previous Years Standardized Test Results 8. Most Recent Report Card

5 Date: Christian Academy of the Cumberlands Academic Excellence in a Christian Atmosphere 325 Braun Street Crossville, TN (931) (student s full name) has applied for admission to the grade at Christian Academy of the Cumberlands. Please send a complete transcript (photocopies) of grades, test results, medical forms, cumulative records, and any other pertinent information you may have which will enable us to assist the student in his/her enrollment process at our school. Thank you for your prompt attention to this important matter. Sincerely, I give permission for the release of all records pertaining to my child.. (Student s Full Name) (Student s Date of Birth) / / (Parent s Signature) (Date) Name of last school attended: Adress: Phone Number: Fax:

6 STUDENT QUESTIONAIRE This page should be filled out by all students entering the 9th-12th grades. The information should be hand written in blue or black ink. 1. Do you consider yourself a dedicated student regarding homework and study habits? Briefly explain your answer. 2. Describe your athletic activities. 3. Briefly tell us about any jobs you do in or outside of the family. 4. If you were to die today and meet God and He should ask you, Why should I let you into my heaven? - What would you say? 5. Write a paragraph about how you make decisions regarding clothes, movies, music, T.V. and friends.

7 STUDENT COMMITMENT Must be read and signed by all students applying for 9th-12th grade. Christian Academy of the Cumberlands is a school dedicated to the glory of God. It is in existence to help you grow spiritually, emotionally, physically and academically. We believe that the biblical writer was correct when he said, The fear of the Lord is the beginning of wisdom. In a very brief manner, let s look at some of the stated purposes of Christian Academy of the Cumberlands: 1. To teach that God is the creator and sustainer of the universe, and that the Lord Jesus Christ is the divine Son of God who came to earth to die for your sins. 2. To teach that God has spoken to us through the Bible, the only infallible Word of God, and to teach you how to study it, understand it, and apply its principles to every part of your daily life. 3. To inspire and motivate you toward a total personal commitment to Jesus Christ so that you might live by and believe personally His Good News, allowing Him to change and shape you. 4. To help you love, obey, respect and help others, as God desires you to look at life from His point of view. 5. To develop within you the ability to assume responsibility for the tasks that have been given you to do, and to be responsible in the way you behave and treat others. 6. To develop your mental abilities for they are given to you by God so that you may take your place in society as a mature, competent, alert, and well-trained person. 7. To help you grow as a thankful and responsible citizen of the country in which God has placed you, to understand our American heritage in order that you may better understand and appreciate the other cultures and peoples of the world. 8. To educate you with academic excellence with a strong emphasis in college preparatory classes in math and science in the context of a commitment to the Christian faith. As a Christian school, we are committed to the teachings of the Bible and we are persuaded that there should be a direct relationship between what a Christian student believes and how he or she behaves. Christian Academy of the Cumberlands students must commit themselves to: Abstain from involvement with tobacco, drugs, alcohol, sexual immorality and profane language on or off campus. Submit without reservation to the authority of your parents, teachers and school officials as given to them by the Lord. This is a committed lifestyle, not just during school hours, but twenty-four hours per day. Violations are considered as breaking a firm commitment that each student makes when voluntarily choosing to attend the school. Participation in drugs, alcohol and/or sexual immorality, on or off campus, will lead to immediate dismissal from Christian Academy of the Cumberlands. As a member of Christian Academy of the Cumberlands, you will be expected to exert a positive influence in your social relationships and to be a responsible member of the Christian Academy of the Cumberlands community. Will you faithfully abide by the school s policies that govern the lifestyle of our students?

8 Student Name Grade Entering MEDICAL RELEASE FORM To: Emergency Personnel I hereby give my consent to any emergency medical personnel to administer necessary treatment to my child,, in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if the situation warrants it. I hereby grant permission for my son/daughter to participate in any and all sports and all extra-curricular activities. I waive, release, absolve, and hold blameless Christian Academy of the Cumberlands and their administrators, teachers, supervisors, physical education directors, managers, persons transporting my child to and from school activities and other participants, from any claim arising out of an injury or sickness to my child. I authorize the personnel at Christian Academy of the Cumberlands to administer first aid to my child in the event of their involvement in an accident, injury or sickness. THIS FORM MUST BE NOTARIZED SIGNATURE OF PARENT OR LEGAL GUARDIAN State of Tennessee County of Cumberland DRIVERS LICENSE # On the day of, 20, before me came, to me known to be the individual described in and who executed the same. NOTARY PUBLIC My Commission Expires: EMERGENCY INFORMATION: Child s Doctor Office Phone Insurance Name Policy # Hospital Preference PICK-UP/ EMERGENCY LIST: Please list the people who are allowed to pick up your child from Christian Academy of the Cumberlands AND can be contacted in case of an emergency. It is the sole responsibility of the parent to notify the school of any changes to this list. Name: Relationship: Home #: Work #: Cell #: Other # Name: Relationship: Home #: Work #: Cell #: Other # Name: Relationship: Home #: Work #: Cell #: Other # Name: Relationship: Home #: Work #: Cell #: Other # Medical History: Previous hospitalization? ( ) No ( ) Yes- If yes, why? Is child allergic to anything? ( ) No ( ) Yes - If yes, what? Any previous diseases or illness? ( ) No ( ) Yes- -If yes, what? Is the child under the care of a doctor? ( ) No ( ) Yes -If yes, for what reason? Does child take any prescribed medications on a daily basis? ( ) No ( ) Yes- If yes, please list. NOTICE: No medication will be dispensed without a written permission (i.e. Tylenol, Motrin, etc) Any history of convulsions? ( ) No ( ) Yes- If yes, please explain. Are there any special instructions that we should know about? ( ) No ( ) Yes- If yes, please list.

9 Enrollment Agreement So that each parent and student understands school policies, we ask that you read the following information and initial next to each statement and sign this form indicating your agreement and understanding of the policies set forth. 1. Students are to show respect in relation to the faculty and in speaking to faculty members. The first rule of conduct should be to show consideration of others at all times. 2. The use of profanity, tobacco, alcoholic beverages, illegal or unauthorized drugs on campus or off campus at any time, are serious violations of the standards of Christian Academy of the Cumberlands and will lead to expulsion. 3. Students are not allowed to leave the school grounds during school hours without permission from parents and proper school authorities. 4. The school is not responsible for the loss of personal property, whether the loss occurs by theft, fire, or any other cause. 5. Christian Academy of the Cumberlands reserves the right of dismissal of any student who persistently and willfully neglects his academic work, exercises poor citizenship, reflects adversely on the Christian principles of the school or generally fails to cooperate with instructors or administration. He or she may be indefinitely expelled. 6. Attire and appearance appropriate to the occasion is expected of all students at all times, and students are expected to adhere to dress code guidelines as described in the student handbook. 7. Many individuals, through their prayers and gifts, made this campus and program possible. Students should consider it a privilege to attend Christian Academy of the Cumberlands, and therefore, do all in their power to keep the buildings attractive. Any student known to deface or destroy school property will be assessed the full cost of repairs and be subject to possible disciplinary action, including dismissal. 8. All students enrolled at Christian Academy of the Cumberlands must have in their school file a birth certificate, social security number, school physical, valid immunization records, and current custody papers if applicable. It is the sole responsibility of the parent to provide the school with any changes or updated legal documents. 9. Christian Academy of the Cumberlands admits students of any race, color, national and ethnic origin to all rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate in the administration of its educational policies, admission policies, scholarships, athletic and other school administrative programs. 10. A student handbook will be furnished to each student. As parents, and students, we agree to read and adhere to the policies and guidelines set forth in the student handbook 11. Any form of homosexuality, lesbianism, bisexuality, fornication or pornography is a violation of the standards of CAC and will lead to expulsion. 12. As parents, we agree that Christian Academy of the Cumberlands may use my child s picture in its promotional and periodical literature for school use. 13. I agree to the financial policies of CAC and I understand that payments for tuition and fees will be made by the first of each month and if late, my account will be billed a late charge of $25. If my payment is past due for more than thirty calendar days my child may be withdrawn from school until my account is made current. 14. My child is permitted to take part in all school activities, including but not limited to, sports and school sponsored field trips, and absolve the school and church from liability to me or my child in case of accident or injury to my child while on campus or during any school sponsored outing. 15. As parents, we sincerely pledge our loyalty to the aims and ideals of the school including attending Parent/Teacher meetings and assisting my children with homework and assignments. 16. As parents, we hereby invest authority in the faculty and administration concerning the discipline of our child as necessary. We further agree that we will support the faculty and administration in discipline at home as needed. 17. As parents, we agree, in accordance with the principle of Matthew 18:15-17, to bring any and all questions and criticisms to the person most directly involved. If we have a question about a specific classroom action or procedure, we will contact the appropriate teacher. If a satisfactory conclusion is not reached, we will then contact the appropriate principal. 18. It is understood that all students are accepted on a trial basis for the first grading period (30 days) before grade placement or enrollment becomes final. 19. CAC is not equipped to handle E.H., S.L.D., A.D.D. or A.D.H.D. children. 20. I agree to comply with and support the spiritual, moral, dress and disciplinary standards and policies of the school and further agree that the school has full discretion in the discipline of my child while under school supervision. 21. Christian Academy of the Cumberlands uses a filtered internet system. As parents, it is our responsibility to notify CAC in writing if we do not want our child to have internet access at school. 22. I understand that if I or any agent acting in my behalf or on behalf of my child, brings any legal action against the school or its agents and such legal action is found in favor of the school or its agents, I will be responsible to pay all legal fees and other expenses related to such action. All disputes shall be settled in binding arbitration. I understand that in signing the Enrollment Agreement, I am agreeing to accept and abide by the rules and philosophy of Christian Academy of the Cumberlands. Parent s Signature Date Parent s Signature Date

10 STATEMENT OF FAITH Christian Academy of the Cumberlands, its staff, and its board members embrace the historic tenets of Christianity as presented in this Statement of Faith. We are in essential agreement with these creeds and confessions when they speak to the doctrinal issues addressed in this statement of faith. We respect and acknowledge the primacy of the family and their churches and refer any other doctrinal questions to parents and their churches for clarification. This statement of faith and all other doctrinal issues that the school takes a stand on will be established and resolved by the EB interpretation of the King James Bible. 1. We believe that the 66 books of the Old and New Testaments are alone the perfect, inspired, infallible, and authoritative Word of God, and as such, rightly interpreted, they are the final authority in faith and practice. (2 Timothy 3:16-17, 2 Peter 1:20-21, Galatians 1:12, Jeremiah 30:2, Psalms 19:7-9, Matthew 24:35, 1 Peter 1:23-25, Revelation 22:18-19) 2. We believe that there is one God, eternally existent in three Persons: Father, Son and Holy Spirit, who is infinite, eternal, and unchangeable in His being, wisdom, power, holiness, justice, goodness, and truth; He alone is sovereign over all things, ordaining whatsoever comes to pass. (Genesis 1:1, Isaiah 45:5-25, Isaiah 43:10-13, Daniel 4:34-37, Malachi 3:6, Acts 17:24-31, 1 John 5:7, Deuteronomy 6:4, Matthew 28:19, Romans 11:33-36) 3. We believe that God created all things out of nothing, for His own glory and good pleasure, and for the display of His eternal power, wisdom, and goodness; having created all things, God created man in His image, male and female, perfect, sinless, and immortal, and He charged mankind with the governance of the created world, to cultivate it for His glory. (Genesis chs. 1 and 2, Genesis 1: 26 & 28, Colossians 1:15-18, Hebrews 1:10, Psalms 24:1, Psalms 19:1) 4. We believe in the historicity of Adam and Eve, our first parents; we believe that though they were created sinless, they did not remain in that perfect state, but willfully and consciously disobeyed their Creator s command. Consequently, the guilt of Adam s sin and his fallen nature are transferred to all mankind. (Genesis 2:7-25, Romans 5:12-19, 1 Corinthians 15:21-22) 5. We believe in the deity and humanity of our Lord Jesus Christ, in His virgin birth during the reign of Caesar Augustus, in His sinless life, in His miracles, in His vicarious and sin-atoning death on a cross by the shedding of His blood, in His bodily resurrection from the dead, in His ascension to the right hand of the Father, and in His personal return in glory and power. (Luke 1:27-35, II Corinthians 5:21, 1 Peter 1:19, Hebrews 4:15, John 20:30-31, John 21:25, 1 Corinthians 15:1-4, Rom. 5:8, Luke 24, John 1:1-4, John 1:14, John 10:30, John 14:10, Philippians 2:5-11, Revelation 19:11-20:4) 6. We believe in the presence of the Holy Spirit, by whose indwelling Christians are enabled to live Godly lives. (Romans 8:7-14, Galatians 5:22-25, II Corinthians 5:17, Galatians 2:19-20, Romans 6:12-13, 1 Corinthians 6:9-11) 7. We believe in the spiritual unity of all believers in our Lord Jesus Christ. (1 Corinthians 12:13, Ephesians 2:11-22, Ephesians 4:3-6, Galatians 3:28) 8. We believe that the chief end of man is to glorify God and enjoy Him forever. (A. Psalms 86:9, Romans 11:36, 1 Corinthians 6:20, 1 Corinthians 10:31, Revelation 4:11, B. Psalms 16:5-11, Psalms 144:15, Isaiah 12:2, Luke 2:10, Philippians 4:4, Revelation 21:3-4) 9. We believe that men are justified by faith in the shed blood of Christ and that only by God s grace and through faith alone we are saved. (Ephesians 2:8-9, Galatians 3:10-14, Galatians 3:22, Galatians 5:4-5, Romans 3:20-28, Romans 4:5-6, Romans 5:1) 10. We believe that faith without works is dead. (James 2:14-26, Ephesians 2:10, Titus 2:14, Galatians 5:6, Titus 2:11-12)

11 11. We believe marriage is the uniting of one man and one woman in covenant commitment for a lifetime. (Genesis 1:27-28, Malachi 2:14-16, Matthew 5:31-32, Matthew 19:3-9, Romans 1:18-32, 1 Corinthians 7:1-16, Ephesians 5:21-33, 1 Peter 3:1-7) 12. We believe that sexual purity is confined to Biblical marriage and that all forms of fornication, adultery, homosexuality, and pornography are morally depraved and they are a perversion to God s mandated design. (Romans 1:24-32, 1 Corinthians 6:9-20, Galatians 5:19-21, Matthew 5:28, Matthew 15:19-20, Hebrews 13:4) 13. We believe in the sanctity of human life, under the government of God, and that the extinguishing of life through abortion, suicide, homicide, or active euthanasia (assisted suicide) is Biblically classified as sin. (Genesis 1:27, Psalms 139:14-15, Psalms 119:73, Job 31:15, Ecclesiastes 11:5, Exodus 20:13) Parent s Signature Date Parent s Signature Date

12 Christian Academy of the Cumberlands 325 Braun Street Crossville, TN (931) Fax: (931) School Reference Form This form must be completed by a current teacher. Student Name: Parent Name: Grade: Homework Obedience Emotional Industry Sociability Judgment Responsibility Parent Involvement Assignments usually turned in on time and done well Assignment often not completed Responds well to authority Unpredictable Defiant Usually well-controlled Excitable; moody; upsets others Apathetic; irresponsible Dependable worker Works just enough to get by Prefers to spend time with others Prefers to be solitary Has difficulty relating to others Tends to be bossy, argumentative Talkative; tends to disrupt class Unusually high maturity Average common sense Immature Excellent; volunteers for tasks Usually accepts when asked Often irresponsible Eagerly seeks to involve themselves Must be contacted to encourage their involvement Always cooperative and supportive Often defensive and unsupportive Have remained uninvolved I recommend this applicant for academic promise: Enthusiastically Strongly Fairly Strongly Without Enthusiasm Not Recommended I recommend this applicant for character and personal promise: Enthusiastically Strongly Fairly Strongly Without Enthusiasm Not Recommended Name: Name of School: Title: School Phone Number:

13 Please fax this form to or mail it to the address at the top of this form. Thank you for your valuable time. Christian Academy of the Cumberlands Discipline Agreement Corporal punishment (paddling) will only be used for excessive Disobedience or for such offences as hitting, using obscene language, Fighting, etc Students 1 st Grade and up Please sign below as to your request: Name of child: Grade: Check one of the following choices: I request for my child to be paddled by a principal or supervisor at Christian Academy of the Cumberlands if the need arises. Parents will be notified by phone as to the incident and circumstances before paddling. I request that I witness my child being paddled by a principal or supervisor at Christian Academy of the Cumberlands if the need arises. I request that my child not be paddled but rather some other form of discipline be chosen. Please Note this could escalate the level of discipline at a quicker rate. Signature of Parents Date

14 Christian Academy of the Cumberlands Volunteer Information Name Address City/State Home Phone Work Phone Children s Grade & Teacher Possible Times Available Possible Days Available Please list what areas you might be interested in working with: PTF Activities Office Lunchroom/Kitchen Classroom Clubs Sports Other (please explain ) All volunteers must be fingerprinted with a background check at the Cumberland County Sheriff s Department.

15 Christian Academy of the Cumberlands Medication Permission Form Students Name Age Grade Teacher Please check all medications that are permitted. Tylenol For complaints of pain such As headache or muscle ache. Ibuprofen For complaints of pain such As headache or muscle ache. Cough drops/throat lozenges For complaints of mild throat Irritation or cough I give my permission for my child to take the medication indicated above. This medication will be administered only by the school nurse. Yes No I would like to be notified prior to medication being given to my child. Yes No Parent or legal guardian s signature Date

16 Christian Academy of the Cumberlands Policy: Web Site/Media Photo Release Form From time to time we take pictures to use in our newsletters and for other school publications, projects, and newspaper articles. One of our publications is our official school web site. As part of this web site we want to be able to showcase student work and activities and recognize their achievements. *The full name, address, phone number, or address of a student will not be provided on a school web site. *Photographs of large groups of students may be posted on a school web site, newsletter, or newspaper article without parental permission as long as individual students are not singled out or identified in any way (e.g. a school assembly, sporting activity or music festival). *Students will be identified by first name only unless we have specific parent permission to use the student s entire name such as when as award is presented. (Photos and rosters of school groups or teams may include full names and or uniform numbers since this information is regularly published in local newspapers as well). Please complete and return this form to your child s teacher by the start of the school year. GRADE: STUDENT NAME: Permission IS granted to use photographs of my child or my child s work on the school web site, newsletter, school publications, or publication in the Crossville Chronicle or Glade Sun given the guidelines sated above. Permission IS NOT granted to use photographs of my child or my child s work on the school web site, newsletter, or newspaper given the guidelines stated above. Parent s Signature: Date: Parents may change their permission at any time by notifying the school in writing.

17 Christian Academy of the Cumberlands Carpool Information Sheet Family Name Carpool Number (Office Use Only) Please list all drivers in your family who has permission to pick up your child: Please list anyone other than family who has permission to pick up your child on a regular basis: Are there any custodial restrictions which involve your child? Is there anyone who is expressly forbidden to pick up your child? Are there any circumstances in which this person would be allowed to pick up your child?

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