STUDENT REGISTRATION FORMS 2020-2021 | Indigo Christian Junior Academy

If you would like to have your application considered to be part of our school family,
please complete the forms below.

Student Name:*

First Middle Last

STUDENT REGISTRATION CHECKLIST

(Please select one)*

New student
Returning Student

PHASE 1 - Before the Admissions Committee can consider an applicant for admission,
the committee must receive the following forms & fees:

*Admissions Application & Parent Cooperation Agreement

*Do you have scholarship award letter? If you answered yes, please present copy with the Admissions Application Form.
If you answered no, are you currently in the process of applying?

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YES
NO

If yes, please specify:

*Student Record Release - permission for Indigo Christian Junior Academy to request / review the following records from previous school.
*(This document is required for new students only.)

*Financial Agreement and meeting with treasurer

*ICJA placement testing and principal interview as needed

*Application Fee $25 - (New Students Only)

PHASE 2 - If your child is accepted, the following documents and fees are
required before the registration process is complete:

*Registration Fee $450.00

Due by:*

Cash*

Check #*

*Media Release - Permission or denial regarding the use of child's name and photo, in all forms of distribution or media

*Handbook Acknowledgment/ Agreement

*CURRENT Physical Examination Form completed by a physician. (before school begins)

*UP TO DATE Florida Certificate of Immunization (Form DH 680)

*Birth Certificate Copy (Passport for foreign students)

*Medical Consent Form

*Student Allergy Form

*Student Medication Form

*Transportation Approval List

*Field Trip Permission Form

*Uniform and PE Shirt Order form with payment

*Morning & Aftercare Registration with payment entered on after Morning & Aftercare registration form.

* Most recent achievement test results

Psych-educational data:
* Psychological Report
* Educational Evaluation
* IEP

* Medical 504 plan

* Most recent report card

* ICJA Placement Test As Needed

* Principal Interview As Needed

Date of interview:

PARENT COOPERATION AGREEMENT

1. As a parent/guardian of a child attending Indigo Christian Junior Academy, I support the principles listed below:

2. I fully assent to Indigo Christian Junior Academy teaching and acting according to their Mission Statement and Philosophy of Education.

3. I will support the beliefs, ideals, curriculum, and teaching methodology of Indigo Christian Junior Academy.

4. I will support the discipline policy of the school as stated in the Parent/Student Handbook.

5. I understand that the school, after consultation with parents, has final responsibility for deciding the placement of my child in the proper grade level.

6. I will be financially responsible for any damage caused to school property by my child.

7. If problems regarding my child's education arise, I will discuss matters directly with my child's teacher and the administration, avoiding gossip or negative talk with others. I will attempt to resolve such difficulties in a manner consistent with Christian behavior.

8. I will support the school and its policies concerning dress code, student conduct and all other matters outlined in the Parents/Student Handbook.

9. I will assume my part of the responsibility of my child's education by supervising assigned homework, keeping regular communication with my child's teacher, and arriving to school on time.

10. I will reinforce to my child that he/she must follow a standard of conduct in accordance with high Christian principles by respecting and obeying willingly those in authority, striving for academic excellence, refraining from dissension, and maintaining high moral standards in words and actions both in and out of school

11. I will support, to the best of my ability, the various activities of the school. I will consider supporting Indigo Christian Junior Academy through prayer and time, as I am able.

12. Should I decide to withdraw or not enroll my student after fees are paid, I understand that all fees (Application, Registration, etc.) are non-refundable knowing that the Academy has established a budget based on enrollment.

We represent that all the above stated information is true and factual, and that we have read and understand the Parent Cooperation Agreement.

Father or Guardian 1 Name:

First Last

Date

Mother or Guardian 2 Name:

First Last

Date

STUDENT MEDICATION FORM

Date of Birth:*

Grade:*

Allergies and/or sensitivities to medications:

Primary Contact Person:*

Contact Number:

Prescription Medications (click plus button on the right to add more):

Medication	Route (oral, topical, injection, inhaler)	Dosage/Amount	Time Given	Reason to be given	Duration: Ongoing/Short Term

Routine Over the Counter Medications (click plus button on the right to add more):

Medication	Route (oral, topical, injection, inhaler)	Dosage/Amount	Time Given	Reason to be given	Duration: Ongoing/Short Term

Name of Parent/Guardian:*

First Last

Date*

Name of Health Care Provider:*

First Last

Date*

Health Care Provider's Address

Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Health Care Provider's Phone Number

MEDIA RELEASE FORM

Indigo Christian Junior Academy uses photos and video in its publications and promotional materials. This form simply gives permission for images of the participant named to be used as outlined below.

Organization: Indigo Christian Junior Academy

Student Name:*

Student Address:*

Student Phone Number:

I hereby consent and authorize Indigo Christian Junior Academy to use my name and/or the names of my family members who are minors, as listed above, as well as my likeness, photos, videos and other information (or that of family members who are minors) for the purpose of news releases, advertising, publicity, publication or distribution in all forms and media. I further consent to such use in their present form and to any changes, alterations, or additions thereto. I hereby release the Florida Conference of Seventh-day Adventists and Indigo Christian Junior Academy from all liability in connection with all such uses.

Parent/Guardian Name:*

Date*

Mark this box if you DO NOT consent or authorize.

I do not consent.

Parent/Guardian Signature:

A parent or guardian must sign above if the participant is under 18.

Date

Witness:

(Anyone who watches as this form is filled out).

Date

IPAD AND COMPUTER USER POLICY

I understand the use of the iPad or computer at ICJA is exclusively for instructional purposes. It is not to be used as entertainment.

1. I may not download an app or any media content on an ICJA iPad or computer without the express consent of my teacher.

2. I will maintain the operating system and not change it.

3. I will not deface the serial number.

4. I will not take an iPad or computer beyond my classroom unless instructed by my teacher.

5. I will leave my iPad or computer closed flat upon my desk.

6. I will never leave my iPad or computer unattended or share a different iPad or computer unless one is loaned by a teacher in case of an emergency.

7. I will be responsible for my iPad or computer assigned to me, and any damages that occur while I am using it. It will be my responsibility to pay my portion of the cost of repairing the device.

8. I will not take photos or record class lectures, discussions, etc. unless given permission from the instructor.

9. I will protect my iPad or computer by ensuring that it remains in its proper case, closed appropriately, and will not stack anything upon it.

10. I will not visit Facebook, twitter, social media sites, or shopping sites while using my iPad or computer. Under no circumstances will I share any personal information on any site, including name, address, phone number, family information, photos, or school location.

11. I recognize that the staff and administration at ICJA has the right to amend this user policy at their discretion. I realize at that time I will be given another User Policy to sign.

Student Name:*

Date*

Parent/Guardian Name:*

Date*

MORNING & AFTERCARE PROGRAM

The Indigo Christian Junior Academy Morning & Aftercare program is committed to assist parents/ guardians before and after school hours by providing a safe, learning, as well as fun, environment for ICJA students. This service is available only on days that school is in session.

Operating Hours:

MORNING CARE:
o Monday - Friday 7:00 a.m. -8:30 a.m.

AFTERCARE
o Monday -Thursday: 3:30 p.m. -6:00 p.m.
o Friday: 1 :30 p.m. - 5:00 p.m.
o Noon Dismissal: 12:00 p.m. -5 or 6 p.m. (depending on the day of the week). Please see 2020-2021 full school year calendar for noon dismissal days. On noon dismissal days a similar schedule as noted below will apply. The additional time will be utilized at the discretion of the Aftercare director.

Morning Care Schedule

Children will remain seated at assigned table with classmates. They will be allowed to socialize, read, do homework, color, and play board games. Snacks WILL NOT be provided in the morning. Please provide a healthy breakfast before arrival.

Aftercare Schedule: Mon - Thurs 3:30 Dismissal Days

3:30-3:40 Attendance
3:40-4:30 *Homework/study time or silent reading 4:30-4:50 *Snack time
4:50-5:30 Free time or organized group games
5:30-6:00 Clean-up, prepare to go home

Aftercare Schedule: Fri - 1:30 Dismissal Days

1:30-1:40 Attendance
1:40-2:30 *Homework/study time or silent reading 2:30-3:00 *Snack time
3:00-4:30 Free time or organized group games
4:30-5:00 Clean-up, prepare to go home

*ALL SCHEDULES ARE SUBJECT TO CHANGE*
Students will be supervised in Gymnasium and/or outside on school grounds.

*Children will be given the opportunity to do their homework assignments during this time. When possible, guidance will be given. However, we do not guarantee that all work will be completed nor will it be checked for accuracy. It must be noted that it is the parents' responsibility to check accuracy, and to see that all assignments have been completed.

*A healthy snack will be provided free of charge during aftercare hours only.
Please be sure to document foods not permitted in your child's diet within the notes section of the attached registration form. If you prefer to send a snack for your child, please follow the guidelines as stated in the ICA handbook.

AFTERCARE WILL NOT BE AVAILABLE ON THE FOLLOWING DATES.
These dates are subject to change. In-the-event that a change occurs, you will be notified as soon as the decision is made

• November 2020 - Day before election day - School is polling location TBA

• November 20, 2020 - Noon Dismissal before Thanksgiving Break

• December 18, 2020 - Noon Dismissal before Christmas Break

• To Be Announced - Last Day of School

WEATHER RELATED EMERGENCIES: For the safety of the students and staff, the Morning care and Aftercare program will be closed. ICA teachers and/or administrative staff will notify you immediately.

FEES
• Morning care - A daily fee of $4.00 will be charged for students arriving prior to 8:00am. The days will be calculated and invoiced at the end of each month. Payments for morning care are due within 2 weeks from date of receipt.

• After school care - The fee is $8.00 daily for each student registered in the Aftercare program. The days will be calculated and invoiced at the end of the month. Payments for aftercare are due within 2 weeks from date of receipt.

• Checks and/or money orders should be made payable to Indigo Christian Academy (ICA). Please include your child's name on the check or money order and the dates for which the payment is covering.

• Payments made in cash will be issued a receipt. It is the responsibility of the parent/guardian to keep their own receipts.for income tax purposes.

• Late pick-up - If student is picked up after the close of Aftercare, a late fee of $20.00 plus $1.00 per minute will be charged.

• Unpaid Fees - Payments not received in the time indicated above will result in suspension from the childcare program.

• Refunds - No money will be refunded in any case.

The parent/guardian/authorized transporter is required to sign out the student location in person.
Student will not be released otherwise.

Medical Emergency Care

IMPORT ANT NOTE: ICJA does not have a nurse on duty. If your child has allergies or other medical problems, please make sure the medical forms you have on file with the school are accurately documented. All medical forms to include: consent to treatment, emergency contacts.

Transportation Approval: All persons who have permission to pick up and transport your child, must be listed on the transportation approval form on file with the school. A copy of this form will be provided to the Morning/ Aftercare director. If the person is not listed, the student will not be permitted to leave campus.

Discipline Policy

The purpose of a discipline policy is to facilitate a positive after-school climate where each student feels safe and secure. The Indigo Christian Academy student code of conduct and discipline process will apply to the Morning & Aftercare program. Parents will be informed of their child's behavior and are required to support the school's decisions. Students will be provided with opportunities to grow in personal and social development and, if they are involved in a discipline concern, are given due process. Rules and regulations outlined in the Indigo Christian Academy Student Handbook will be applied to the Morning & Aftercare program. All students enrolled in this program are expected to obey them.

1st Offense - The parent/guardian will be informed and the student will receive a warning.

2nd Offense - A parent conference will be held and the student will be suspended from Aftercare program for one week.

3rd Offense - Possible expulsion from Aftercare program.

Please return the completed Morning & Aftercare registration with payment to the school office.

Morning/Aftercare Procedure Acknowledgement & Registration

I have carefully read and understood the Morning & Aftercare Program Operating Procedures. I acknowledge and agree to the fees, due dates, discipline policy and rules / regulations. I will uphold and support the policies put in place so that my child may attend Indigo Christian Academy's Morning and/or Aftercare program. In the event of an emergency and I cannot be reached, I give permission to Indigo Christian Academy to arrange emergency care for my child.

Student Signature:*

Parent/Guardian Signature:*

Date*
MM slash DD slash YYYY

Indigo Christian Academy admits students of any race, color and national origin. Indigo Christian Academy does not discriminate on basis of race, color or national origin in the administration of its educational policies, admission policies, scholarships, athletic programs or other school sponsored events.

ADMISSIONS APPLICATION

Student Information

Student Name:*
First Middle Last

Preferred Name (If different than above):

Gender:*

Male

Female

Date of Birth:*
MM slash DD slash YYYY

Child's Age:*

Address of Child:*

City:*

Zip Code:*

Phone Number:*

Please Select Student's Ethnic Background:*

African-American

Asian

Caucasian

Latino

Native American

Family Information

Father Name:

Marital Status:

Select One:

Natural Parent

Step-Parent

Mother Name:

Marital Status:

Select One:

Natural Parent

Step-Parent

Who has legal custody of this student? Please select all that apply.*
Both parents
Father
Mother
Guardian 1
Guardian 2

With whom does this student live? Please select all that apply.*
Both parents
Father
Mother
Guardian 1
Guardian 2

Guardian 1 Name:

Guardian 1 Marital Status:

If related to student, please specify:

Guardian 2 Name:

Guardian 2 Marital Status:

If related to student, please specify:

Parent/Guardian 1 Email:

Parent/Guardian 1 Phone Number:

Employer/Occupation:

Work #:

Parent/Guardian 2 Email:

Parent/Guardian 2 Phone Number:

Employer/Occupation:

Work #:

Please list the names of each person authorized to view the academic record of this student:*

Are all fees/charges paid to date to current/previous school?*

YES

NO

If no, please provide a brief explanation:

Please provide requested information about the siblings of this student (click plus button on the right to add more):
Name: Age: Name of Current School:

Educational History

List your child's skills, interests and abilities:

Has your child ever been dismissed, suspended, or disciplined at any school?*

YES

NO

If yes, please provide name of school and a brief explanation:

Does your child have any medical or health conditions that affects learning needs?*

YES

NO

If yes, please explain:

Has your child ever been tested, diagnosed, or enrolled in any ESE (Special Education Program) or had a Medical 504 plan or an IEP (Individual Education Program)?*

YES

NO

If yes, please specify and discuss the results in the space below (it would be very helpful to also have a copy of the report).

Christian Education

Briefly describe your understanding of Christian education:*

How important is it to have your child in a Christian school and why?*

Educational Goals

What do you believe your role as a parent is in your child's educational success?*

What role(s) do you envision Indigo Christian Junior Academy having in relation to these goals both in the coming school year and long term?*

What is your child's emotion about the possibility of attending Indigo Christian Junior Academy? Please select all that apply:*
Ecstatic
Happy
No emotion
Not over the top excited
Unhappy
Anxious
Sad
Other

Religious Background

Father/Guardian 1: What is your church background?

Do you currently attend church?:

If yes, where?:

Briefly describe what having a personal relationship with God means to you:

Mother/Guardian 2: What is your church background?

Do you currently attend church?:

If yes, where?:

Briefly describe what having a personal relationship with God means to you:

Is child a baptized member of a church family?:*

YES

NO

If yes, where?:

How did you hear about Indigo Christian Junior Academy?

Indigo Christian Junior Academy Website
Advertisement - Flyer, Radio, Newspaper
Family member

If it was a referral from a current Indigo Christian Junior Academy family, please provide name so that we may properly thank them:

Other:

MEDICAL CONSENT FORM

Student Name:*

Date of Birth:*
Month
Day
Year

Gender:*

Male

Female

Grade for 2021-2022 School Year:*

Please select one:*

New Student

Returning Student

Name of first emergency contact:

Phone number of first emergency contact:

Name of second emergency contact:

Phone number of second emergency contact:

Primary Student Address:*

City:*

Zip Code:*

Please list all siblings (first and last names) attending ICJA (click plus button on the right to add more):

Student Allergies (click plus button on the right to add more)
Please list student allergies to food: Please list student allergies to medication: Please list any other student allergies:

Has your child ever had an anaphylactic reaction?*

YES

NO

If yes, please describe and put approximate date of latest incident:

Does your student have an EPI pen/device?*

YES

NO

If yes, will your student have an EPI pen/device at school?

YES

NO

Note: If your student is prescribed an EPI pen/device and you choose to not provide one for your student at school, we do NOT have "extra" medication at school in case of anaphylactic emergency. We will initiate our emergency protocol in any anaphylactic situation regardless if student has an EPI pen/device on campus but we STRONGLY urge you to provide one for your student.

Medical Condition/Current Diagnosis:

Asthma?*

YES

NO

Does your student have an inhaler?

YES

NO

If yes, will your student have an inhaler at school?

YES

NO

Type 1 diabetes?*

YES

NO

If yes, does your student have an insulin pump?

YES

NO

Type 2 diabetes?*

YES

NO

Seizures?*

YES

NO

If yes, when was your student's last seizure?

If yes, when was your student's last seizure? Please describe type of seizure:

Sickle cell trait or disease?*

YES

NO

ADD/ADHD*

YES

NO

Hearing loss?*

YES

NO

Any other medical condition that affects your student's long term health?*

YES

NO

If yes, please describe:

Does your student have a Medical 504 plan?*

YES

NO

If yes, please list:

Note: All medications that are brought to ICJA must have a current pharmacy label/original container and paperwork filed at the office. Only approved medications may be in student's possession ONLY AFTER BEING GIVEN APPROVAL FROM ICJA STAFF

Over the Counter Medications:

A Doctor's Prescription must be on file with Indigo Christian Junior Academy before we can administer any over the counter drugs.

I authorize Indigo Christian Junior Academy trained staff and trained assistants to administer to my student over-thecounter medications, if warranted and per manufacture instructions such as:

Cream/sprays for itches/rashes?*

YES

NO

Ointments/sprays for mild scrapes?*

YES

NO

Acetaminophen/Ibuprofen for mild head and/or body aches/fever?*

YES

NO

Antacids for upset stomach aches?**

YES

NO

Signed Consent for Treatment Valid for School Year 2020-2021 at Indigo Christian Junior Academy

1. Medical Consent to Treat
a.) I authorize Indigo Christian Junior Academy to treat minor medical occurrences such as scrapes, bumps, minor injuries, removal of simple splinters and similar and authorize ICA nursing team to communicate pertinent medical information (medical conditions, allergies, and/or medical regimens) to be given to those who teach/supervise my student.
b.) I authorize emergency medical care to be given to my student by an appropriate health care provider under whatever conditions are necessary to preserve the life, limb or well-being of my student. I realize that ICJA will contact me at the earliest possible time or prior to treatment if possible.

2. lnsurance Coverage
I understand that the student accident insurance carrier by the Florida Conference of Seventh-day Adventists is the insurance carrier. Financial responsibility for any accident incurred during school sponsored functions will be negotiated with Florida Conference and with the student's family health insurance carrier. This may be a lengthy process.

3. Participation in Sports Activities
a.) I authorize my student to participate in athletics (PE class, playing during recess and breaks) realizing that such activities involve potential for injury. I acknowledge that even with the best coaching and supervising and the strict observation of the rules, injuries are still possible. On rare occasions, these injuries are severe and may result in disability, paralysis, and even death.
b.) I remain fully responsible for any legal responsibility, which may result from any personal actions taken by my student.

All consents above are valid for the school year 2020-2021 and are intended to allow Indigo Christian Junior Academy staff/personnel and faculty to better serve my student. I agree that a photocopy of this consent or a copy sent by email, fax or form of electronic health record is to be accepted by any health care provider.

Signature of Parent/Legal Guardian:*

Printed Name:*

Date*
Month
Day
Year

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Who is personally known to me

Whose identity I proved on the basis of (write below)...

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ICJA Witness Signature:*

Printed Name:*

Date*
Month
Day
Year

FIELD TRIP PERMISSION FORM

Participant's Name (Student):*

Participant's Address:*

Participant's Telephone Number:

I hereby consent and authorize my child to attend all field trips sponsored by Indigo Christian Junior Academy for the 2020-2021 school year. I understand that I will be given a letter stating the particulars of each field trip to sign and return to the classroom teacher. The purpose of this form is to give consent should the student fail to return the letter as well as give consent to all PE classes to be held off campus.

Parent/Guardian Signature:*

Date*
Month
Day
Year

Mark this box if you DO NOT consent or authorize:
I do not consent.

Participant/Guardian Signature:

A parent or guardian must sign above if the participant is under 18.

Witness (Anyone who watches as this form is filled out):

Date
Month
Day
Year

HANDBOOK ACKNOWLEDGEMENT AGREEMENT

I have read, understood, accepted and will comply with the Indigo Christian Junior Academy Handbook. I agree to support and abide by all school standards, policies, rules, procedures and those emphasized above.

Student Signature:*

Parent/Guardian Signature:*

Date*
Month
Day
Year

TRANSPORT PICK-UP APPROVAL

Student Name:*

Grade:*

PLEASE LIST ALL PERSONS AUTHORIZED TO PICK YOUR CHILD FROM SCHOOL.
STUDENT WILL NOT BE RELEASED TO ANYONE THAT IS NOT ON THIS LIST.

(Click plus button on the right to add more):
Name of Authorized Person: Phone Number: Relationship to Child:

Parent/Guardian Signature:*

Date
Month
Day
Year

Please list student allergies to food:	Please list student allergies to medication:	Please list any other student allergies:

Name of Authorized Person:	Phone Number:	Relationship to Child:

STUDENT REGISTRATION FORMS 2021-2022

STUDENT REGISTRATION CHECKLIST

PARENT COOPERATION AGREEMENT

STUDENT MEDICATION FORM

MEDIA RELEASE FORM

IPAD AND COMPUTER USER POLICY

MORNING & AFTERCARE PROGRAM

Morning Care Schedule

Aftercare Schedule: Mon - Thurs 3:30 Dismissal Days

Aftercare Schedule: Fri - 1:30 Dismissal Days

Medical Emergency Care

Discipline Policy

Morning/Aftercare Procedure Acknowledgement & Registration

ADMISSIONS APPLICATION

MEDICAL CONSENT FORM

FIELD TRIP PERMISSION FORM

HANDBOOK ACKNOWLEDGEMENT AGREEMENT

TRANSPORT PICK-UP APPROVAL