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                  Admission Application

                 Becker Adventist School
                 A Seventh-Day Adventist Christian School

                3561 Covington Hwy.

                 Decatur, Ga. 30032

                   404/299-1131

           Complete and return this application, transcript

              release form and the application fee

            (non-refundable)

    Students Name                        Grade            School Year

     ________________________         _______            ___________

A: Applicant Data

Student’s Last Name:______________________ First Name:_______        ________ Middle Name:_______

Nick Name:_______________________ Social Security Number:_______________________________

Sex:______ Age:______ Date of Birth:_____________________ Place of Birth: _______________________________________

Address:____________________________________________________________________________________________________

                          Street                                                                City                    County                          State                  Zip Code

Home Phone:_________________ Student’s Cell Phone:__________Student’s Email Address:__________________

School District Child Resides in: ____________________________________________ Citizenship:_________________________

Primary Language:_______________________ Is this applicant a foreign student with a F-1 visa? Yes_______ No_______

Religious Affiliation:________________________________ Church Attending:_________________________________

Baptized: Yes_________ No______ Date of Baptism:__________Place of Baptism:_______________________________

B: Family Data

If separated or divorced, with which parent does child reside? □ Father □ Mother □ Guardian

To whom should notices of activities be sent? _____________________________________________

C: If your child is a new student(Returning students may skip to section D.)
1. How did you first become interested in BAS?_______________________________________
2. Name of school your child is transferring from:_______________________________________
3. Address of school transferring from:_______________________________________________

                                                                            Street                                     City                                 Zip

School Phone:__________________________ School FAX: ___________________________

Please list…

any specific church ministries in which you or your child may be involved (example: Bible school teacher, church committees, etc.

____________________________________________________________________________________________________________________________________________________________________________

Has your child…

1. Ever been tested or recommended for a special education program? □ Yes □ No

                Ever had physical or learning disability? □ Yes □ No

                Ever been recommended to take medication for a learning or attention disorder? □ Yes □ No

               If you answered yes to any of the above questions,  please explain:  _____________________________________________________________________________________

______________________________________________________________________________________

2. Received honors, taken special lessons, or been involved in special programs? (music, athletics, etc.)____________________________________________________________

3. Ever been expelled or suspended from school? □ Yes □ No

4. Ever taken illegal drugs of any kind, including alcohol or tobacco? □ Yes □ No

D: Supplemental Information

Does your child …

have any ongoing health problems? (asthma, epilepsy, etc.) □ Yes □ No

If “Yes”, please identify:______________________________________________________________

______________________________________________________________________________________

As Parents…

Please list the areas you’d like to volunteer to help in our school, i.e., room mom/dad, volunteer driver, maintenance…

____________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

E: Continuing Consent to Treat

We, the undersigned parents or guardian of (Name of Student)___________, a minor, do hereby consent to

any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered to said minor under the general or special instructions of

(Name of Physician)_____________M.D., or any physician the school  or organization may call, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is

understood that reasonable effort will be made to contact the doctor listed above before any other physician is called by the school or other organization.

It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize Becker Adventist School or the physician to exercise their best judgment as to the requirements of such diagnosis or treatment.

This consent shall remain in continuous effect until revoked in writing and delivered to the physician named above or to the school or organization entrusted with the custody of said minor.

Allergic To:

Medications:____________________________________________________________________

Other:_________________________________________________________________________

Medical Conditions:____________________________________________________________________________

The above named student ( ) is ( ) is not covered by health insurance.

Company Name:______________________________ Policy #__________________________

Address:_____________________________________ Phone #__________________________

____________________________________ Daytime Phone:_________________Or_________________

Signed Father/Mother/Legal Guardian

_________________________________      Daytime Phone:_________________Or__________________

Other Emergency Contact

___________________________________  Daytime Phone:_________________Or__________________

Other Emergency Contact

____________________________________ Date: _______________________________

Witness (must be dated)

F: Student Transportation Authorization

(Authorization must be in writing for anyone other than a custodial parent to pick up a child from school.)

____________I will be picking up my child from school. I can be reached at the following number(s):

_______________________________(Daytime)

_______________________________(After school hours)

_______________________________(Cell and/or Pager)

____________My child will be riding with: ___________________  _________(After school hours)

                                                                                           (Phone)

                                                   __________ ___________________(After school hours)

                                                                                          (Phone)

_____________________________                         __________________________________

Signed Father/Mother/Legal Guardian                                                         Date

G: Field Trips

The following is an authorization for your child to attend all Becker Adventist School sponsored field trips. Notification will be sent home to parents prior to a planned field trip as to where, when, cost (if there is any), appropriate attire for student dress if it is a non uniform day, etc. Of course, parents will still have the option of refusing permission for a student to go on a particular field trip by simply calling the school or sending a note to the teacher, even if they have signed the following authorization. Your signature below

will save a separate permission slip for each school activity throughout the school year.

I give permission for my child, _____________________________________________, to go on all field trips sponsored by Becker Adventist School with the conditions listed above.  This is for the _20____ - _20_____ school year.

Parent’s or Guardian’s Signature: ______________________________________________

Printed Name: ______________________________________________

H. Release

I authorize release of pictures that may be taken of my child and articles he/she may write for use in the Friday Flyer, school brochures, school news paper, school web site, and other publications produced by the school. I understand that I will be notified for an additional release should my child’s picture be considered for an advertisement in any magazines or newspapers.

Parent’s or Guardian’s Signature: ______________________________________________

Printed Name: ______________________________________________

I. Volunteer Driver Questionnaire

Georgia-Cumberland Conference of Seventh-day Adventists

The following information is required for all drivers of school-sponsored trips. If you plan to be a driver for a field trip, please complete the following and provide a copy of your insurance card and a copy of your driver’s license. Additional forms may be obtained in the school office if more than one family member will be driving on field trips. Thank you.

Name:____________________________________________ Are you over 21 years of age?____________

Driver’s License Number: __________State in which license is held: ________Expiration date:_________

Do you have a current auto insurance policy? _________Yes _________No

Carrier:_____________________________________________________ Expiration Date:____________

Limit of Liability $____________________________

Medical/PIP Limit: $____________________________

Have you been involved in any fault accidents within the last three (3) years? _________Yes _________No

If “Yes,” please describe:___________________________________________________________________

___________________________________________________________________________

I understand that should I be involved in an accident while driving for the school, my insurance will be primary.

Further, I agree not to carry more passengers than the official rated load capacity for my vehicle. All vehicle occupants will be required to wear seat belts (no double belting allowed).

Driver’s Signature:_________________________________________ Date:_________________________

Driver’s Printed Name:______________________________________

J: Parent/Teacher Concern Protocol

The Georgia-Cumberland Conference K-12 Board of Education has voted the following procedure for adoption and use in all schools. The procedure is mindful of due process and founded on the Biblical principles of Matthew 18. Any questions regarding the fundamental philosophy and/or procedures prescribed should be directed to the Office of Education.

Parent*/Teacher Concern Procedure:

1. **Parent is to meet with the teacher alone or as a family to deal with the concern. Under no circumstance is the concern to be discussed with any other party. At each instance in which a concern is registered, the teacher should have the right to address the concern directly.

2. If the concern remains unresolved after Step 1, the unresolved concern is to be taken to the school principal for the purpose of securing assistance in finding resolution. A meeting among the three parties (principal, parent and teacher) is to be held with the principal chairing the meeting. The principal is to keep minutes of the meeting including all relevant issues and/or agreements discussed. The minutes are to be reviewed by all parties prior to the completion of the meeting.

3. Should the concern involve the school principal, the school board chairman will serve as the facilitator. The Georgia- Cumberland Conference Office of Education will also have representation present.

4. If the concern remains unresolved then the parent will be referred to the Executive Committee of the School Board. At this point, the Office of Education is to be directly involved.

5. If, after the aforementioned steps prove unsuccessful, and the concern remains unresolved, a final appeal of the issue can be made to the School Board. In order to insure fairness, the teacher is to be present at this meeting. A representative from the Office of Education will be invited by the school board chairman to participate in the discussion of the issues. Should the parent with the concern be a member of the school board, he/she will remove himself/herself from the decision-making process relative to the issue at hand. A final resolution to the concern will be acted upon at this level. All parties are to be officially notified, in writing, of the School Board's decision.

* or other individual

** all meetings with the teacher(s) and/or principal must be by appointment

After having read the Parental Concern Protocol, I agree to follow the Parent/Teacher Concern

Procedure while my child is enrolled at Becker Adventist School.

Parent’s Signature:____________________ Parent’s Signature:___________________________________

Parent’s Printed Name:________________ Parent’s Printed Name:________________________________

Date:_________________________

K: Fees and Conditions

The application fee is not refundable. The filing of this application is not binding upon either parent(s) or the school. Admissions testing may be required at an additional expense for students applying for kindergarten through 8th grade. The Admission is based on available openings, acceptable school records, references, test results and a personal interview with the principal and/or teacher.

A separate financial agreement must be signed prior to a student beginning classes. Fees include an application fee (new students only), a registration fee for all students, activity fee and tuition. Please refer to the current student handbook for the current rates.

I have read the Becker Adventist School Handbook. I agree to abide by all school regulations if my child is accepted. I affirm that, to the best of my knowledge, all statements made herein are true. As a parent or guardian, I understand failure to share all requested information may jeopardize my child’s acceptance and/or continued enrollment at BAS.

Parent’s Signature:___________________ Parent’s Signature:___________________________________

Parent’s Printed Name:___________________________________

 Parent’s Printed Name:________________________________

I have read the Becker Adventist School Handbook. I agree to abide by all school regulations if I am accepted

Student’s Signature:______________________________________

L: The Admissions Process at Becker Adventist School

Listed below are the steps for admission to BAS. Please call the school office if you have any questions.

Returning Students:

1. Complete and return this application

2. Returning sixth-grade students submit documentation of 2nd MMR and proof of chicken pox or a signed, notarized immunization waiver

3. Signed Financial Agreement

*note—all returning students undergo a review by the admissions committee

New Students:

1. Complete and return this application with the non-refundable application fee.

2. Complete and return the Principal/Teacher Recommendation and Request for Records form.

3. Provide the school with references.

When your application is received, you will be given three reference forms by people who fit into the following categories and returned to BAS:

a. An adult who knows your child well (not a family member).

b. A minister, youth minister, or Bible school teacher from the church you attend.

c. An academic classroom teacher from your child’s most recent school.

4. Interview with principal and/or teacher.

             Upon completion of the above steps, a personal interview will be scheduled.

5. Upon acceptance, the following documentation and completed paperwork will be required:

a. State certified copy of Birth Certificate

b. Copy of Social Security Card or notarized waiver

c. Georgia State Certificate of Ear, Eye and Dental Examinations

d. Georgia State Certificate of Immunization or notarized waiver

e. School Entry Medical Examination

f. Signed Financial Agreement (will be mailed to you by our treasurer)

As you make application, keep in mind that our concern is for the happiness, success, and development of your child. We promise to provide a quality education in a Christian environment. Our teachers, administrator and programs all work together to provide a safe and pleasant environment where your child’s character will develop and mature. Your involvement in Christian education is an investment in your child’s future.

It is this school’s goal to provide true education that means “more than a preparation for the life that now is…it (education) has to do with the whole being, and with the whole period of existence possible to man.” --Education, page 13