Dr John A Mckinney Christian Academy



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Student Registration Checklist

Completed Application for Admission.

Picture Identification of Parent or Guardian.

Original Birth Certificate or Birth Card.

Social Security Card of Parent/Guardian and Student.

DH 3040 Student Health Examination Form (yellow form).

DH 680 Florida Certificate of Immunization Form (blue form).

Academic Report Card from School Last Attended (Grades 1 through 5).

Completed Media Release Form.

Completed Enrollment Agreement Form.

Completed Tuition Payment Information Form.

Completed Student Health Form.

Completed Parent Notification of Disciplinary Policy.

Registration Fee-$100.00 due with COMPLETED Application Packet.

Pre-admission Screening and Interview completed.

| |Dr. John A. McKinney Christian Academy |Grade Level |

| |New Birth Baptist Church Cathedral of Faith International |Kindergarten |

| |2300 Northwest 135th Street • Miami, Florida 33167 |First Grade |

| |Telephone: (786) 318-3818 • Fax: (305) 685-6886 |Second Grade |

| |Dr. Victor T. Curry, Chancellor/CEO |Third Grade |

| | |Fourth Grade |

| | |Fifth Grade |

|Application For Admission |

|Last Name |First Name |Middle Name |

| | | |

|Gender |Date of Birth |Present Age |Social Security Number |

| | | | |

|Student Address |Apartment # (if applicable) |

| | |

|City |State |Zip Code |

| | | |

|Telephone Number |Last School Attended |Last Grade Completed |

| | | |

|Family Information |

|Mother’s or Female Guardian’s Name |Father’s or Male Guardian’s Name |

| | |

|Address (if different from student) |Address (if different from student) |

| | |

|City/State/Zip Code |City/State/Zip Code |

| | |

|Home Phone (if different from student) |Home Phone (if different from student) |

| | |

|Cellular Phone |Cellular Phone |

| | |

|Employer |Employer |

| | |

|Work Phone |Work Phone |

| | |

|Siblings presently attending Dr. John A. McKinney Christian Academy or will be attending (please list names and grades) |

|Academic Information |

|Name and address of school last attended |Telephone Number |

|Has your child ever repeated a grade? If yes, list grade and year grade was repeated. |

|Has student been in: □Spec. Ed. □Speech □ESOL □Other: ________________________ |

|Has student been expelled or referred to an alternative program for disciplinary reason? Yes ____ No ____ |

|Has your child ever been tested for or enrolled in a special program (gifted, learning disabled, special needs, etc.)? If yes, please give details. |

| |

| |

|Emergency Contact Information |

|Name |Relationship |Phone Number |

|Name |Relationship |Phone Number |

|Name |Relationship |Phone Number |

|Name of Doctor |Address |Telephone Number |

|Hospital Preference |Insurance Company |Insurance Policy Number |

|Medical Conditions |Allergies |

|Parental Consent for Medical Treatment |

| |

|Occasionally, an accident or extreme illness of a student makes it necessary for school personnel to contact the parent/guardian for consent to administer |

|emergency medical attention. By signing below, you are authorizing the school personnel to administer First Aid on your child as recommended by the Dade County |

|Health Department. Should your child need emergency medical attention, these expenses are the responsibility of the parent/guardian of the child. In the event a |

|parent/guardian cannot be contacted, signing below also gives school personnel the authority to secure appropriate medical treatment. Furthermore, I will not hold|

|school personnel, Dr. John A. McKinney Christian Academy, and the New Birth Baptist Church Cathedral of Faith International liable for any injuries that may |

|develop as a result of the delivery of First Aid and/or the decision to secure appropriate medical treatment for the child in question. |

|Parent/Guardian Signature |Date |

| | |

|Individuals Authorized | |Individuals Unauthorized |

|to Pick-up Student | |to Pick-up Student |

| | | |

| | | |

| | | |

|Parent Contract |

| |

|In submitting this application for admission to the Dr. John A McKinney Christian Academy, I agree to: |

|Support the standards and philosophy of the Academy, as well as the academic, behavioral, spiritual, dress, disciplinary, and moral policies set forth by the |

|Academy. |

|Fully cooperate with the teachers and the administration of the Dr. John A McKinney Christian Academy, and understand that failure to do so may result in the |

|expulsion of my child from the Dr. John A McKinney Christian Academy. |

|Accept the responsibility for my child’s education by supervising homework, encouraging and supporting my child’s academic progress, meeting with my child’s |

|teacher(s) and attending four mandatory parent-teacher conferences for the school year. |

|Release, indemnify and hold harmless Dr. John A McKinney Christian Academy, the New Birth Baptist Church Cathedral of Faith International, its agents and |

|employees, from any and all actions and claims for personal injury or damages of any kind resulting from the transportation of my child in vehicles owned or leased|

|by the Dr. John A. McKinney Christian Academy and/or the New Birth Baptist Church Cathedral of Faith International. |

|Allow my child to participate, if selected, in activities and/or appear in pictures and/or videos, which promote the Dr. John A. McKinney Christian Academy. |

|Pay tuition in full when due and any outstanding balance, even if I voluntarily withdraw my child or my child is dismissed from the Academy and I understand that |

|records will not be forwarded to another school or academy until all financial obligations have been satisfied. |

|Dr. John A. McKinney Christian Academy reserves the right to refuse any application, or dismiss any child at any time, for unacceptable work or conduct, or for any|

|other reason the Academy deems necessary. Submission of this application and/or payment of fees are not considered to be binding upon Dr. John A. McKinney |

|Christian Academy. My signature below indicates that I have read, understand, and agree with the Parent Contract as stated above. |

|Parent/Guardian Signature |Date |

| | |

Non-Discriminatory Policy

Dr. John A. McKinney Christian Academy admits students of any race, color, national and ethnic origin to all the 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 and loan programs, and athletic and other school administered programs.

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New Birth Baptist Church Cathedral of Faith International

2300 Northwest 135th Street • Miami, Florida 33167

Telephone: (786) 318-3818 • Fax: (305) 685-6886



Dr. Victor T. Curry, Chancellor/CEO

Application for Admission

Enrollment application will not be accepted without registration fee.

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