Lighthouse Church School Registration Form

Dear Parents, It is our school policy to have a complete set of documents for each child before school starts. This registration packet must be turned in before the first day of school with all other necessary documents. The parent or guardian is responsible for submitting copies. Please do not submit original forms or documents.

The Registration Form includes the following:

Basic Information
Release authorization
Tuition Agreement
Fundraiser Agreement
School Handbook Agreement
Authorization to Treat a Minor

In addition to the registration form, we also require the following supporting documents:

Copy of Birth Certificate
Copy of Immunization Record
Oral Health Assessment Form

The Registration fee for the school year costs $600 (non-refundable). Registration is non-refundable. Monthly Tuition for K-8th grade is $550 for 10 months (September-June), due on or before the 1st of each month. All incoming kindergarten students must undergo a mandatory kindergarten readiness evaluation before the first day of school. The evaluation fee is $75 (nonrefundable).

Thank you for your cooperation and participation,

Mrs.Annie Cho

Principal

Lighthouse Church School

Student Name:

Place of Birth:

For School Year:

Date of Birth:

1

Gender:

Male‎ Female‎

Date of Application:

Home Address:

City:

State:

STUDENT INFORMATION

Applying to Enter Grade:

Zip Code:

PARENT/GUARDIAN INFORMATION

Father/Guardian Name:

Home Address:

City:

State:

Zip Code:

Occupation or Name of Employer:

Work Phone:

Cell Phone:

Email:

Mother/Guardian Name:

Home Address:

City:

State:

Zip Code:

Occupation or Name of Employer:

Work Phone:

Cell Phone:

Email:

1

Parent's Marital Status:

Married‎ Divorced‎ Other‎

Other Marital Status:

With whom does the student reside?:
Father and/or Mother - Guardian name - other

1

With whom should correspondence be sent to?

Father‎ Mother‎ Both‎

List siblings:
Name - Age - Grade - Current school. If no siblings, please type "none".

Applicant's current school:

School address:

School phone number:

Current grade:

1

Has your child ever repeated a grade?:

Yes‎ No‎

If yes, which grade was repeated?:

1

Has your child ever been referred to, enrolled in, or attended a program for learning difficulties, testing, special education, or had an I.E.P. evaluation?:

Yes‎ No‎

If yes, please explain below and submit a copy of the I.E.P. to the school office:

RELEASE AUTHORIZATION

The undersigned legal guardian(s) of the above named student do hereby authorize and consent to the release by The Lighthouse Church School of said student to the following persons: (List full name for each person. A telephone call is not sufficient for the school to release a child to someone other than the named individuals below. You must send a signed and dated note.)

The following people are authorized to pick up your child:
Name - Relationship - Phone number

1

May your child leave the school property at any time?:

Yes‎ No‎

It is hereby acknowledged and further agreed by the undersigned that the Lighthouse Church School will not, under any circumstances, release said child to anyone other than who are named above unless instructed otherwise by the undersigned. I, with the undersigned electronic signature at the end of this registration, warrant the truthfulness of the information provided in this application.

TUITION AGREEMENT

I hereby agree to pay Lighthouse Church School (Santa Monica Foursquare Church) a tuition fee of $550 per month, or the amount specified here

Enter amount

per month, for my student, due on or before the first day of each month (or the next available school day), for ten (10) consecutive months (September - June) of the school year:

This tuition payment is for the education of my student. I understand that in the event I decide to withdraw my student from the school, I must provide a 30-day notice to the school.

Additionally, I agree to pay the yearly registration fee of $600 upon enrollment or re-enrollment in the school. It is understood that failure to fulfill any outstanding fees or tuition may result in consequences such as withholding of records, imposition of additional fees, penalties, and interest, as well as possible separation of my student from the school. I acknowledge that unpaid balances may be referred to attorneys and/or collection agencies, and I will be responsible for any related fees.

Acceptance:

I have read and agree to "Tuition Agreement".

Fundraiser Participation Agreement

I hereby agree to participate in the fundraisers organized by The Lighthouse Church School. I understand that to maintain affordable tuition, the school will hold various fundraisers throughout the year. Among these, three fundraisers are mandatory, and my child will be required to take part in them. Should I wish to be exempt from these mandatory fundraisers, I will submit a payment of $100 per fundraiser, totaling $300, to The Lighthouse Church School. Failure to participate in each fundraiser will result in a $100 exemption fee per event.

I acknowledge that failure to make these payments may lead to the possibility of my child's expulsion from the school.

Acceptance:

I have read and agree to "Fundraiser Participation Agreement".

THE LIGHTHOUSE CHURCH SCHOOL HANDBOOK AGREEMENT

I have read and understand the school handbook and agree to all contained rules, policies, and procedures. I understand that failure on the part of the parent or child to cooperate with the contained rules, policies, and procedures will result in disciplinary action including expulsion from The Lighthouse Church School. These rules, policies, and procedures may change at any time at the school’s discretion.

Acceptance:

I have read and agree to "The Lighthouse Church School Handbook Agreement".

AUTHORIZATION TO TREAT A MINOR

No student is admitted to school without the following:

Authorization To Treat A Minor:

I/we, the undersigned parents, or legal guardian of a minor, do hereby understand, consent and authorize The Lighthouse Church School to call an emergency ambulance in case of accident or acute illness, and to arrange for necessary medical, surgical, and dental care, in case I am not I/we are not immediately available. I/we also authorize and consent to an X-ray examination, anesthetic, medical or surgical treatment rendered by any member of the Medical Practice Act, or a dentist licensed under the provisions of the Dental Practice Act on the staff of any acute general hospital holding a current license to operate a hospital from the state in which that hospital is located. It is further understood that this authorization is given in advance of any specific diagnosis or treatment or hospital care deemed advisable in their best judgement. It is understood that efforts shall be made to contact the undersigned prior to rendering treatment to the student, but that none of the above treatment will be withheld if the undersigned cannot be reached. I/we understand that medical treatment authorized by The Lighthouse Church School is my financial responsibility. Furthermore, if my child(ren) are injured while at The Lighthouse Church School or off the premises, it is my complete responsibility. I/we understand that my child(ren) has clearance to participate in physical education class or any other school sports; (or) state the reason(s) your child(ren) cannot participate in physical education by attaching a letter from their physician. A note of excuse must be sent directly to the school by a medical provider listing how long the inability to participate in physical activities applies. If your child has any food or drug allergies, or needs medication during school hours, please notify the office or teacher prior to the first day of or returning to school.

TB Skin Test:

All students entering a L.A. county school for the first time are required to present evidence of a tuberculosis skin test. A T.B. skin test (mantoux) is required each year.

Written Immunization Record:

Students entering a California school for the first time on or after March 5, 1986 must provide a written immunization record or receipt of each required vaccine dose (or of an exemption to the immunization requirements). This record must show the date (at least month and year) of each required dose. Newly entering pupils who currently need additional vaccine doses or who lack written record of having received doses are no longer allowed a ten-school-day period of conditional attendance while awaiting receipt of currently due immunization(s) or while producing a written immunization record.

Health Physical:

All students entering school must have had a complete doctor’s physical examination within one year of admission.

Does your child have any known food or drug allergies?

No Yes

If yes, please explain:

2 Epi Pens must be provided if necessary: one for the classroom and one for the office.

Does your child have any physical handicaps?

Has your child's school attendance ever been interrupted for a period of a month or more due to medical reasons? Approximate dates and details:

Has your child ever had surgery?

Is your child currently under medical treatment? (Reasons, medications, and names and contact information for doctor(s) rendering treatment)

Has your child ever been treated by a psychiatrist/psychologist? (Dates of treatment, treating physician, contact information, and medications prescribed)

In case of an emergency, who should be contacted?
Name - Phone Number - Relationship

INSURANCE INFORMATION

Insurance Company Name:

Policy Number:

Subscriber's Name:

Relationship:

Physician's Name:

Physician's Phone Number:

Dentist's Name:

Dentist's Phone Number:

Release of Liability:

I assume full responsibility for my child after they leave the school premises. This includes field trips.

I have answered the questions accurately and certify that no information has been withheld or misrepresented. I understand that discovery of substantial falsification or omissions can result in immediate dismissal.

My student is a normal child who is a safe companion for other children.

Parent/Guardian Electronic Signature:

Date:

Parent/Guardian Electronic Signature:

Date:

Acceptance:

I understand that checking this circle constitutes a legal signature confirming that I acknowledge and agree to the above terms.

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