SRCCHA 2019-2020 Application for Enrollment 1 Parent2 Student3 Additional Family Information4 Family Emergency Information5 Prospective Family Questions6 Signatures7 Payment Items marked with an asterisk are required.Current or Prospective*CurrentProspectiveAre you a current or prospective family to SRCCHA?Parent InformationFather's Name* First Last Father's OccupationFather's Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's Home Phone*Father's Mobile PhoneFather's Email Address* Enter Email Confirm Email Mother's Name* First Last Mother's OccupationMother's Home Address Same as father's address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mother's Home Phone same?yesnoIs the mother's home phone the same as the father's?Mother's Home Phone*Mother's Mobile PhoneMother's Email Address* Enter Email Confirm Email Student Count*How many students are you registering?Student 1 InformationStudent 1 Full Name* First Last Nickname Student 1 DOB* What is the student's date of birth?Student 1 Grade Entering*KG1G2G3G4G5G6D1D2What grade is the first student entering?Enrollment Options K-G5 - Art & Music: K–G5 students will be taught the grammar of art and music and introduced to the great artists and composers. Students will also learn to draw and sing. K and G1 students will have their own individual classes. G2 and G3 students will play the recorder. No homework will be assigned for Art and Music. Math Lab (K-D2): Open to all students Math Lab will be directed tutoring in all levels of math. This will be an after-school lab from 2:10pm-3pm one day a week on Thursdays. G6 - Art & Music for G6: Student have the choice of taking Art & Music or Math. Dialectic (D1 & D2) - students have the choice of Math and/or Advanced Latin *Pre-Algebra, Algebra and Geometry (G6 – D2) students will receive classroom instruction and homework assignments. Students will be assessed by the Math Tutor and placed in an appropriate course level. Advanced Latin students (D1–D2) will receive classroom instruction and homework assignments. Student 1 Enrollment Options Art & Music (G6) Adv. Latin (D1, D2) Pre-Algebra (G6, D1)* Algebra (D1, D2)* Geometry (D2)* Choose enrollment options for student.Student 1 Math Lab*YesNoWould you like to enroll the student in Math Lab?Student 1 Medical ConditionsDoes this student have any medical condition(s) and/or allergies?Student 1 Medical SymptomsPlease be observant for these medical symptoms in my child during Academy hours.Student 1 Course of ActionPlease take this course of action during Academy hours should these symptoms (or other situations requiring medical attention) occur.Student 1 MedicationsPlease list any regularly used medications for the student.Student 1 Nut AllergyYesNoDoes this student have nut/peanut allergies?Student 1 EpiPenYesNoDo you wish to supply an EpiPen to SRCCHA?Student 1 Acetaminophen?*I authorize SRCCHA staff to administer Acetaminophen to my child as needed.I authorize SRCCHA staff to administer Acetaminophen to my child only after contacting me first.I do not authorize SRCCHA to administer Acetaminophen to my child.SRCCHA requires prior parental permission to administer Acetaminophen to a student. We will only give Acetaminophen and no other kind of medication. An email will be sent to the student’s parents after administering Acetaminophen. Please indicate your preference by selecting ONE of the appropriate choices above.Student 2 InformationStudent 2 Full Name* First Last Nickname Student 2 DOB* Student 2 Grade Entering*KG1G2G3G4G5G6D1D2What grade is the second student entering?Student 2 Enrollment Options Art & Music (G6) Adv. Latin (D1, D2) Pre-Algebra (G6, D1)* Algebra (D1, D2)* Geometry (D2)* Choose enrollment options for student.Student 2 Math Lab*YesNoWould you like to enroll the student in Math Lab?Student 2 Medical ConditionsDoes this student have any medical condition(s) and/or allergies?Student 2 Medical SymptomsPlease be observant for these medical symptoms in my child during Academy hours.Student 2 Course of ActionPlease take this course of action during Academy hours should these symptoms (or other situations requiring medical attention) occur.Student 2 MedicationsPlease list any regularly used medications for the student.Student 2 Nut AllergyYesNo Does this student have nut/peanut allergies?Student 2 EpiPenYesNoDo you wish to supply an EpiPen to SRCCHA?Student 2 Acetaminophen?*I authorize SRCCHA staff to administer Acetaminophen to my child as needed.I authorize SRCCHA staff to administer Acetaminophen to my child only after contacting me first.I do not authorize SRCCHA to administer Acetaminophen to my child.SRCCHA requires prior parental permission to administer Acetaminophen to a student. We will only give Acetaminophen and no other kind of medication. An email will be sent to the student’s parents after administering Acetaminophen. Please indicate your preference by selecting ONE of the appropriate choices above.Student 3 InformationStudent 3 Full Name* First Last Nickname Student 3 DOB* Student 3 Grade Entering*KG1G2G3G4G5G6D1D2What grade is the third student entering?Student 3 Enrollment Options Art & Music (G6) Adv. Latin (D1, D2) Pre-Algebra (G6, D1)* Algebra (D1, D2)* Geometry (D2)* Choose enrollment options for student.Student 3 Math Lab*YesNoWould you like to enroll the student in Math Lab?Student 3 Medical ConditionsDoes this student have any medical condition(s) and/or allergies?Student 3 Medical SymptomsPlease be observant for these medical symptoms in my child during Academy hours.Student 3 Course of ActionPlease take this course of action during Academy hours should these symptoms (or other situations requiring medical attention) occur.Student 3 MedicationsPlease list any regularly used medications for the student.Student 3 Nut AllergyYesNoDoes this student have nut/peanut allergies?Student 3 EpiPenYesNoDo you wish to supply an EpiPen to SRCCHA?Student 3 Acetaminophen?*I authorize SRCCHA staff to administer Acetaminophen to my child as needed.I authorize SRCCHA staff to administer Acetaminophen to my child only after contacting me first.I do not authorize SRCCHA to administer Acetaminophen to my child.SRCCHA requires prior parental permission to administer Acetaminophen to a student. We will only give Acetaminophen and no other kind of medication. An email will be sent to the student’s parents after administering Acetaminophen. Please indicate your preference by selecting ONE of the appropriate choices above.Student 4 InformationStudent 4 Full Name* First Last Nickname Student 4 DOB* What is the student's date of birth?Student 4 Grade Entering*KG1G2G3G4G5G6D1D2What grade is the fourth student entering?Student 4 Enrollment Options Art & Music (G6) Adv. Latin (D1, D2) Pre-Algebra (G6, D1)* Algebra (D1, D2)* Geometry (D2)* Choose enrollment options for student.Student 4 Math Lab*YesNoWould you like to enroll the student in Math Lab?Student 4 Medical ConditionsDoes this student have any medical condition(s) and/or allergies?Student 4 Medical SymptomsPlease be observant for these medical symptoms in my child during Academy hours.Student 4 Course of ActionPlease take this course of action during Academy hours should these symptoms (or other situations requiring medical attention) occur.Student 4 MedicationsPlease list any regularly used medications for the student.Student 4 Nut AllergyYesNo Does this student have nut/peanut allergies?Student 4 EpiPenYesNoStudent 4 Acetaminophen?*I authorize SRCCHA staff to administer Acetaminophen to my child as needed.I authorize SRCCHA staff to administer Acetaminophen to my child only after contacting me first.I do not authorize SRCCHA to administer Acetaminophen to my child.SRCCHA requires prior parental permission to administer Acetaminophen to a student. We will only give Acetaminophen and no other kind of medication. An email will be sent to the student’s parents after administering Acetaminophen. Please indicate your preference by selecting ONE of the appropriate choices above.Student 5 InformationStudent 5 Full Name* First Last Nickname Student 5 DOB* Student 5 Grade Entering*KG1G2G3G4G5G6D1D2What grade is the fifth student entering?Student 5 Enrollment Options Art & Music (G6) Adv. Latin (D1, D2) Pre-Algebra (G6, D1)* Algebra (D1, D2)* Geometry (D2)* Choose enrollment options for student.Student 5 Math Lab*YesNoWould you like to enroll the student in Math Lab?Student 5 Medical ConditionsDoes this student have any medical condition(s) and/or allergies?Student 5 Medical SymptomsPlease be observant for these medical symptoms in my child during Academy hours.Student 5 Course of ActionPlease take this course of action during Academy hours should these symptoms (or other situations requiring medical attention) occur.Student 5 MedicationsPlease list any regularly used medications for the student.Student 5 Nut AllergyYesNoDoes this student have nut/peanut allergies?Student 5 EpiPenYesNoDo you wish to supply an EpiPen to SRCCHA?Student 5 Acetaminophen?*I authorize SRCCHA staff to administer Acetaminophen to my child as needed.I authorize SRCCHA staff to administer Acetaminophen to my child only after contacting me first.I do not authorize SRCCHA to administer Acetaminophen to my child.SRCCHA requires prior parental permission to administer Acetaminophen to a student. We will only give Acetaminophen and no other kind of medication. An email will be sent to the student’s parents after administering Acetaminophen. Please indicate your preference by selecting ONE of the appropriate choices above. Additional Family InformationSiblings not attending SRCCHAFull NameAgeGrade EnteringSchool Attending Click the plus to add additional students.Special CareIn the space above, please write anything you think would be necessary or helpful to us to care for your child(ren) while in class (e.g., allergies, glasses, learning disabilities, behavior problems, etc.). Please note that SRCCHA is not equipped to educate students with serious emotional, physical, or learning disabilities.GoalsBriefly describe your goals for the upcoming Academy Year.Committee AssignmentAs we look to assign each family to a committee do you have any spiritual gifts or special skills you would like to share? Family Emergency InformationFamily's Physician Name*Family's Physician Phone*Insurance CompanyPolicy or Group #Emergency Contact InformationPreferred Parent*MotherFatherWhich parent should be contacted first in an emergency?Mother's Phone Numbers*Phone #Type (H/M/W) Please list one or more phone numbers with the type (H=Home, M=Mobile, W=Work). Click plus to add multiple phone numbers.Father's Phone Numbers*Phone #Type (H/M/W) Please list one or more phone numbers with the type (H=Home, M=Mobile, W=Work). Click plus to add multiple phone numbers.Third Preference Contact Name First Last This is the next person to contact after the parents.Third Preference Contact RelationshipWhen relationship does this person have to the students?Third Preference Contact Phone NumbersPhone #Type (H/M/W) Please list one or more phone numbers with the type (H=Home, M=Mobile, W=Work). Click plus to add multiple phone numbers.Fourth Preference Contact Name First Last This is the next person to contact after the parents.Fourth Preference Contact RelationshipWhen relationship does this person have to the students?Fourth Preference Contact Phone NumbersPhone #Type (H/M/W) Please list one or more phone numbers with the type (H=Home, M=Mobile, W=Work). Click plus to add multiple phone numbers. Prospective Family QuestionsYou said you were a prospective family. Please complete these additional questions for prospective families only.Education HistorySchool Name and Contact Informationfrom Gradeto Grade Please list preschools/schools/tutorials previously attended, starting with the most recent.Phonics/Grammar Experience*YesNoHas instruction been received by your child(ren) for Phonics and Grammar?Phonics/Grammar Curriculum*What curriculum was used for Phonics and Grammar?Latin Experience*YesNoHas instruction been received by your child(ren) for Latin?Latin Curriculum*What curriculum was used for Latin?Logic Experience*YesNoHas instruction been received by your child(ren) for LogicLogic Curriculum*What curriculum was used for Logic?Homeschool Choice*Why have you chosen to homeschool your child(ren)?Classical Christian Understanding*What is your understanding of the Classical Christian approach? Have you used this in your own schooling?Note: We would appreciate your support in answering the following questions as candidly as possible. SRCCHA is not staffed to handle children with serious learning disorders, behavioral issues or physical disabilities. We provide only group tutoring and a safe environment for children to learn. (If more than one child is applying, please note which child you are referring to when answering.) Learning DisordersDoes your child have any condition (learning disorders) that may affect his/her academic achievement or class involvement and would require regular or special attention? If so, please specify:Behavioral IssuesDoes your child have any behavioral issues that may affect his/her class involvement and would require regular or special attention?Previous SuspensionHas your child ever been suspended by a previous academic setting? If so, please specify:Father's Testimony*For the father, briefly summarize your personal testimony of salvation. Please include your views on Jesus Christ.Mother's Testimony*For the mother, briefly summarize your personal testimony of salvation. Please include your views on Jesus Christ.ReferencesDo you know anyone who currently attends SRCCHA? This person(s) may be used as a reference for your family. SignaturesPhoto Release*We allowWe do not allowDo you allow SRCCHA to use digital images of your children for the SRCCHA website, brochure or other purpose incorporating pictures that will be viewed publicly. No names will be attached to these images, unless permission is granted in writing for that purpose.Confirm Handbook Read* We have read the SRCCHA Family Handbook and will abide by its guidelines and rules. Check box above to confirm.Confirm Accuracy* We (I) hereby certify that all the foregoing information is accurate and true. We (I) have carefully considered enrolling our child(ren) in the Severn Run Classical Christian Homeschool Academy. We (I) agree to submit to the philosophy, programs, academic and disciplinary rules outlined by the Board in the Family Handbook. We (I) understand that admission is granted by the Board, and that such admission may be terminated at any time. Confirm Statement of Faith* We have read and agree to having our child(ren) taught at SRCCHA based on the SRCCHA 2019–2020 Statement of Faith. Check box above to confirm.Confirm Financial Commitment* We have read, understood, and agree to abide by the SRCCHA 2019–2020 Covenant of Financial Commitment. We promise to pay our child(ren)’s entire annual tuition and Math Lab (if enrolled), for the coming Academy Year, even if we withdraw our child(ren) from the Academy before, or during, the Academy Year. Check box above to confirm.Confirm Medical Waiver* I/We voluntarily release Severn Run Evangelical Presbyterian Church (Millersville, MD), and the Board members of Severn Run Classical Christian Homeschool Academy (SRCCHA) and their representatives, including Parents-of-the-Day and Tutors, from any and all liability related to the activities of the homeschool Academy. I/We understand in the event that medical attention is required, that every effort will be made to contact me/us. However, if I/we cannot be contacted, I/we give my/our permission to the staff to secure the services of a licensed physician to provide the necessary treatment including anesthesia, surgery, medication, and intravenous (IV) for my children named within this application. Check box above to confirm.Confirm Student Rules of Conduct* Our Dialectic student(s) have read and agree to abide by the SRCCHA 2019–2020 Student’s Rules of Conduct, or, we have read the SRCCHA Student’s Rules of Conduct to our Grammar student(s) and agree to abide by those Rules. Check box above to confirm.Confirm Dress Code* Our Dialectic student(s) have read and agree to abide by the SRCCHA 2019–2020 Dress Code Policy, or, we have read the SRCCHA Dress Code Policy to our Grammar student(s) and agree to ensure they abide by that Policy. Check box above to confirm.Our names below indicate our agreement with all of the above statementsFather's Signature*Mother's Signature*D1-D2 Student's Signature*D1-D2 Student's Signature PaymentApplication Fee Price: $50.00 Application Fee Price: $100.00 Total $0.00 You're almost finished! Once you click the Submit button you will receive instructions on how to pay the application fee via check.CommentsPlease enter any comments or issues you encountered while using this form.CommentsThis field is for validation purposes and should be left unchanged.
