STUDENT REGISTRATION FORM
STUDENT INFORMATION
Student Name:
Grade:
DOB:
PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian Name:
Natural Mother/Father
Stepmother/Stepfather
Guardian (Check or circle one)
Relationship to student:
Grandmother/Grandfather
Email Address:
Phone:
Cell Phone: provider
Street Address:
Mailing Address:
City:
State:
Zip Code:
FAMILY DOCTOR CONTACT INFORMATION
Physician Name:
Phone:
GRANDPARENT INFORMATION
We would like to send them information about SBCA and invite them to Grandparent’s Day.
(1) Name:
Mailing Address:
City:
State:
Zip
Code:
State:
Zip
Code:
(2) Name:
Mailing Address:
City:
PICK UP AUTHORIZATION AND EMERGENCY CONTACTS
Provide at least two emergency contacts at minimum.
(1)
Authorized to Pick Up
Name:
Emergency Contact
Authorized to make medical decisions
Phone:
Cell Phone:
Relationship to student:
(2)
Authorized to Pick Up
Name:
Emergency Contact
Phone:
Authorized to make medical decisions
Cell Phone:
Relationship to student:
1
(3)
Authorized to Pick Up
Emergency Contact
Name:
Authorized to make medical decisions
Phone:
Cell Phone:
Relationship to student:
(4)
Authorized to Pick Up
Emergency Contact
Name:
Authorized to make medical decisions
Phone:
Cell Phone:
Relationship to student:
MEDICAL CONCERNS / ALLERGIES / SPECIAL INSTRUCTIONS
Please complete and sign the Medical Release Form at the end of this Registration
Please list any medical concerns:
List any student allergies:
Other Special Instructions:
MEDICATION PERMISSION
We realize there may be a time where a child will ask for medication for one reason or another. These times include
(but are not limited to) headaches, stomachaches, toothaches, cuts and scrapes, sore throats, coughs and colds. We
want to be able to help out where we can and are willing to administrate medication to your child if you want us to. If
you would rather us call you before giving medication, please indicate below. It has been our experience that some
children ask for medication more than others and if we need to address this at a later time, we can do so.
The staff at South Baldwin Christian Academy has permission to give my child the indicated medication:
Medication Allowed (age/weight appropriate):
Acetaminophen (Tylenol)
Yes
No
Ibuprofen (Advil, Motrin)
Yes
No
Cough Drop
Yes
No
Benadryl Cream Hydrocortisone Cream (on itchy spots)
Benadryl Oral Medication (pills or liquid)
Antacid ( Tums or Children's Pepto)
Neosporin /BandAid )
Yes
Yes
Yes
Yes
No
No
No
No
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MEDIA RELEASE
I grant permission to South Baldwin Christian Academy (from now on known as SBCA) and its subordinates, to use my
name and/or photographs for use in SBCA publications such as recruiting brochures, newsletters, and magazines, to
use my name/and or photographs-videos on display boards, to use my name and/or photographs-videos in electronic
versions of the same publications or on the SBCA website or other electronic forms or media and for submissions for
articles in local and national newspapers to be published.
I hereby waive any right to inspect or approve the finished photographs-videos or printed or electronic matter that
may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive
any right to royalties or other compensation arising from or related to the use of the photograph.
I hereby agree to release, defend, and hold harmless SBCA and subordinates, including any firm publishing and/or
distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any
claims, damages or liability arising from or related to the use of the photographs-videos, including but not limited to
any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise,
that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or
distribution.
Please check the paragraph below which is applicable to your present situation:
I am 18 years of age or older and I am competent to contract in my own name. I have read this release before
signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to
address any specific questions regarding this release, and I agree that my failure to do so will be interpreted as a free
and knowledgeable acceptance of the terms of this release.
I am the parent or legal guardian of the below named child. I have read this release before signing below, and I
fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific
questions regarding this release, and I agree that my failure to do so will be interpreted as a free and knowledgeable
acceptance of the terms of this release.
I do not grant permission for my name and/or photographs to be used in SBCA publications.
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TUITION AND FEE SCHEDULE
Grade
Tuition
Registration Fee
Curriculum
Fee
K3 – K4
$3600
$155
None
After
Care/Study
Hall
$1000
Kindergarten – 5th Grade
Morning Care
$400
$3600
$155
$100
$1000
$400
th
6 – 8 Grade
$3800
$155
$200
$1000
$400
9th – 12th Grade
$4000
$155
$300
$1000
$400
th
TUITION
Tuition
Study Hall/After Care/Morning Care
Total Tuition
PAYMENT AND FEES
Tuition Payment Options (select one):
Pay Tuition in Full (Use amounts
above)
Pay Tuition Monthly - $100 Setup Fee
for first student, plus $20 per student
thereafter.
Curriculum Fee:
Other:
Total Payment and Fees Due at
Registration
For Office Use Only
Amount Received
$
Cash
Check
Date:
4
DEMOGRAPHIC SURVEY
The information needed for this survey is required for accreditation statistics. Please fill it out completely. Note: SBCA
does not discriminate on the basis of race, color, national or ethnic origin in the administration of its educational
policies, athletic, and other school-administered programs.
# of Years
Student(s) Name
Gender
Grade
Attended
Ethnic Origin
SBCA
*Key: (please list the ethnic origin that MOST closely describes each student)
C=Caucasian | AA=African-American | H=Hispanic | A=Asian | Other=(specify)
Family Structure of SBCA Student:
Other Children Living in the Home:
Traditional Family (Father, Mother & Children Living
(Age)
(Age)
Together)
Single Parent
Other:
(Age)
(Age)
(Age)
(Age)
Parents: Father’s Full Name
Mother’s Full Name
Guardian/Other’s Name
(Living with Student?
(Living with Student?
(Living with Student?
Yes
Yes
Yes
No)
No)
No)
Vocation and Socioeconomic Level of Parent(s)
(Choose the one that most closely describes your career and household income range.)
Vocation
Parent
Socioeconomic Level
Christian Service
Mother
Father
$15,000 – $20,000 yr.
Professional
Mother
Father
$21,000 – $25,000 yr.
Managerial Executive
Mother
Father
$26,000 – $30,000 yr.
Marketing Sales
Mother
Father
$31,000 – $35,000 yr.
Skilled Craft or Trade
Mother
Father
$36,000 – $40,000 yr.
Military
Mother
Father
$41,000 – $45,000 yr.
Homemaker
Mother
Father
$46,000 – $50,000 yr.
5
Retired
Mother
Father
$51,000 – $55,000 yr.
Student
Mother
Father
$56,000 – $60,000 yr.
Educator
Mother
Father
$61,000 – $65,000 yr.
Medical (Dr. or Dentist)
Mother
Father
$66,000 – $100,000 yr.
Self Employed
Mother
Father
$100,000 – Above yr.
Law Enforcement
Mother
Father
Unemployed
Mother
Father
Other (Specify)
Mother
Father
Language(s) Spoken in the Home:
_
Religious Affiliation
Check the denomination which most closely fits your beliefs and/or church attendance.
Assembly of God
Christian Orthodox
Episcopal
Lutheran
Mormon
Wesleyan
Muslim
Other:
Do you attend church?
Baptist
Church of Christ
Foursquare
Methodist
Nazarene
Coptic Orthodox
7th Day Adventist
Yes
No
How did you find out about SBCA?
Internet Search
Direct Mail Piece
Catholic
Church of God
Greek Orthodox
Missionary Alliance
Non-Denominational
Presbyterian
Pentecostal
If so, how often do you attend?
Facebook
Family/Friend
Hwy. 59 Location
Other:
PARENT/GUARDIAN VOLUNTEER SERVICE
Parent(s)/guardian(s) of SBCA are required to contribute at least 10 volunteer hours during the school year. Please
check the following volunteer opportunity areas you are interested in being contacted about.
Cleaning
Office Work
Substitute Teaching
Events
Landscaping
Organizing After School Program Projects
Tutoring
Construction
Set Building/Design
Other:
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STUDENT HANDBOOK AGREEMENT
I have read the SBCA Student Handbook and agree to the terms and policies listed in the handbook and will support
the philosophy of SBCA.
TUITION AND FEE SCHEDULE
Grade
Tuition
Registration Fee
Curriculum Fee
K3 – K4
$3600
$155
None
After Care/Study
Hall
$1000
K – 5th Grade
Morning Care
$400
$3600
$155
$100
$1000
$400
th
6 – 8 Grade
$3800
$155
$200
$1000
$400
9th – 12th Grade
$4000
$155
$300
$1000
$400
th
TUITION
Tuition
Study Hall/After Care/Morning Care
Total Tuition
PAYMENT AND FEES
Tuition Payment Options (select
one):
Pay Tuition in Full (Use
amounts above)
Pay Tuition Monthly - $100
Setup Fee for first student, plus
$20 per student thereafter.
Curriculum Fee:
Other:
Total Payment and Fees Due at
Registration
For Office Use
Only
Amount Received
$
Cash
Check
Date:
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REGISTRATION AUTHORIZATION
Signatures below indicates authorization of all pages of this document.
Date:
Signature of Student:
Signature of Parent or Legal
Guardian (if under 18 years of age):
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