“a school with a heart, in the please attach a current ... · agapÉ boarding school 2 previous...
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AGAPÉBOARDINGSCHOOL
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ADMISSIONAPPLICATION(Pleasecompleteentireapplication)
Pleasetypeorprintclearly: Personcompletingapplication?__________________________________
Date:__________________________________HowdidyouhearaboutAgape?__________________________________
ApplicantInformation IsapplicantaU.S.citizen?___________________________________
Nameofchild:_____________________________________________ S.S.#:_______-_____-________ Age:___________
Birthplace:__________________________________________ Birthdate:____/_____/______ CurrentGrade:_______
Ethnicity:____________________________________________ ReligiousAffiliation:_________________________________
Isyourchildpresentlylivingathome?Y/NIfno,pleaseexplain:_____________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Haircolor:_____________________Eyecolor:____________________Height:__________Weight:___________
Tattoos:___________________________________________Scars:____________________________________________________
Pleaselistfriendsorrelativesthatyourchildmighttrytocontact:(includephonenumbers)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
PLEASEATTACHACURRENTPICTUREOFYOURTEEN
HERE
“A school with a heart, in the heart of Missouri”
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AGAPÉBOARDINGSCHOOL
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PreviousPrograms Hasyourchildhadpreviousplacementsoutsidethehome?Y/N
Ifyes,pleaselistallotherprograms,schools,familymembers,andhospitalorotherinstitutions:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
ParentInformation(Ifdeceasedpleasenotedateandcause)
Father’sName:_____________________________________ Age:__________Occupation:___________________________
Address:________________________________________City:________________________State:_________Zip:___________
HomePhone:_____________________________WorkPhone:____________________________Fax:___________________
Cell:__________________________________________ Email:_________________________________________________________
Bestmethodofcontact:________________________________________ Besttimetocontact:________________
Mother’sName:__________________________________________Age:_____Occupation:__________________________
Address:________________________________________City:________________________State:_________Zip:___________
HomePhone:_____________________________WorkPhone:____________________________Fax:___________________
Cell:__________________________________________ Email:_________________________________________________________
Bestmethodofcontact:________________________________________ Besttimetocontact:________________
Stepfather’sName:_______________________________________Age:_____Occupation:________________________
Address:_______________________________________City:________________________State:_________Zip:___________
HomePhone:_____________________________WorkPhone:____________________________Fax:___________________
Cell:__________________________________________ Email:_________________________________________________________
Bestmethodofcontact:________________________________________ Besttimetocontact:________________
Stepmother’sName:__________________________________Age:_________Occupation:________________________
Address:________________________________________City:________________________State:_________Zip:___________
HomePhone:_____________________________WorkPhone:____________________________Fax:___________________
Cell:__________________________________________ Email:_________________________________________________________
Bestmethodofcontact:________________________________________ Besttimetocontact:________________
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AGAPÉBOARDINGSCHOOL
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Pleasegivethefollowinginformationofeachimmediatememberofyourfamily:
NAME AGE RELATION CURRENTLYLIVINGWITH
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Personstonotifyincaseofemergency(otherthanparents)
Name:_________________________________Relationship:________________________Phone:______________________
Name:_________________________________Relationship:________________________Phone:______________________
SocialHistory:Pleasedescribethepersonalityofyourchildinthefollowingphases)
Birthtosixyearsold:________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Seventotwelve:______________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Thirteentopresent:__________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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AGAPÉBOARDINGSCHOOL
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PresentProblems
Whatareyourchild’scurrentbehaviorproblems?_______________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
FamilyRelationships(pleasedescribeyourchild’srelationshipwithfamilymembers)
Father:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Mother:________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Stepfather:____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Stepmother:___________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Siblings:_______________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Pleasedescribeanyothersignificantrelationshipswithfamilymembers:_____________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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AGAPÉBOARDINGSCHOOL
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Divorce/SeparationHistory
Areparent’sdivorced?Y/NIfyes,when?______________Whohascustody?_________________________
Hasthedivorceorseparationbeenanissueforyourchild??Y/NIfyes,explain:___________________
_________________________________________________________________________________________________________________
Anypastorcurrentcustodybattles?Y/NIfyes,explain:_______________________________________________
_________________________________________________________________________________________________________________
Haveeitherparentremarried?Y/N Hasthisbeenanissuewithyourchild?Y/N
Ifyes,pleaseexplain:________________________________________________________________________________________
_________________________________________________________________________________________________________________
Adoption
Wasyourchildadopted?Y/N Ifyes,when?____________________________________Age?______________
Wherewasyourchildadoptedfrom?___________________________ Previousadoptionhomes?Y/N
Pleaseexplainanyspecialcircumstancesleadinguptotheadoption:__________________________________
_________________________________________________________________________________________________________________
Hastheadoptionbeenanissueforyourchild?Y/NIfyes,explain:___________________________________
_________________________________________________________________________________________________________________
Dotheyknowinformationabouttheirbiologicalparents?Y/NIfyes,explain:_______________________
_________________________________________________________________________________________________________________
Havethebiologicalparentsbeeninvolved?Y/NIfyes,explain:________________________________________
_________________________________________________________________________________________________________________
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AGAPÉBOARDINGSCHOOL
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BehavioralHistory
Hasyourchildeverdemonstratedaggressiveorviolentbehavior?Y/NIfyes,pleaseexplain:
_________________________________________________________________________________________________________________
Hasyourchildhadanyinvolvementwiththelegalsystem?Y/NIfyes,pleaseexplain:
_________________________________________________________________________________________________________________
Hasyourchildevertalkedabout,threatened,orattemptedsuicide?Y/NIfyes,pleaseexplain:
_________________________________________________________________________________________________________________
Doesyourchildhaveahistoryofself-mutilation?Y/NIfyes,explain:________________________________
_________________________________________________________________________________________________________________
Hasyourchildhadanychangesinbehaviorormood?Y/NIfyes,explain:___________________________
_________________________________________________________________________________________________________________
Whendidthesechangesoccur?_____________________________________________________________________________
Hasyourchilddiscussedanyabnormalthoughts?Y/NIfyes,explain:________________________________
_________________________________________________________________________________________________________________
Pleasedescribethehistoryofanyspecificdisorderyourchildhashad:________________________________
_________________________________________________________________________________________________________________
Pleasecheckanyofthefollowingcharacteristicsthatapplytoyourchild:
❑ Shyortimid ❑ Withdrawn ❑ Daredevilbehavior❑ Bed-wetting ❑ Crueltoanimals ❑ Playwithfire❑ Unhappy ❑ Fearoflosingcontrol ❑ Verbalabuse❑ Witnesstoviolence/abuse ❑ Strangethoughts ❑ Difficulttocontrol❑ Aggressivetowardsothers ❑ Loner ❑ Destructive❑ Restless ❑ Ganginvolvement ❑ Physicalabuse
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AGAPÉBOARDINGSCHOOL
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Ifyourchildhaseverrunaway,pleaseanswerthefollowingquestions:
Howmanytimeshasyourchildranaway:__________ When?______________ Alone?Y/N
Howlongwashegone?_____________________Didhecallhome?Y/NDistancetraveled?____________
Whodidhestaywith?_____________________________ Wasyourchildinvolvedinillegalactivity?Y/N
Ifyes,pleasedescribeindetail:_____________________________________________________________________________
_________________________________________________________________________________________________________________
Whatwasthereasonyourchildranaway?________________________________________________________________
SocialRelationships
Doesyourchildmakefriendseasilyorhavedifficultymakingfriends?_________________________________
Doesyourchildprefertobealone?Y/N Doesyourchildgetalongwellwithothers?Y/N
Areyourchild’sfriendsusuallyyounger,older,orthesameage?_______________________________________
Areyourchild’sfriendsusuallythesamesexoroppositesex?___________________________________________
Hasyourchildrecentlychangedfriendgroupsorstoppedhangingoutwithcurrentfriends?Y/N
Whattypeofpeergroupsdoesyourchildspendtimewith?_____________________________________________
Whatareyourfeelingsaboutyourchild’sfriends?________________________________________________________
SexualHistory
Toyourknowledge,hasyourchildbeensexuallyactive?________________________________________________
_________________________________________________________________________________________________________________
Hasyourchildhadanysexualproblems?__________________________________________________________________
_________________________________________________________________________________________________________________
Hasyourchildexhibitedanysexualidentityissuesorinappropriatesexualbehavior?_______________
_________________________________________________________________________________________________________________
Toyourknowledge,hasyourchildeverbeensexuallyabusedorraped?_______________________________
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AGAPÉBOARDINGSCHOOL
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Historyofabuse:(Sexual,Physical,andEmotional)
SpecificHistoryofAbuse
SpecifyWhetherVictimorOffender:_______________________________________________________________________
Incest:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Rape:__________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Molestation:__________________________________________________________________________________________________
_________________________________________________________________________________________________________________
SexualPerpetration:_________________________________________________________________________________________
_________________________________________________________________________________________________________________
PhysicalAbuse:_______________________________________________________________________________________________
_________________________________________________________________________________________________________________
Verbal/EmotionalAbuse:____________________________________________________________________________________
_________________________________________________________________________________________________________________
Neglect:_______________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Legalmeasurestaken:_______________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Child’sbehaviorandattitudeexhibited:____________________________________________________________________
_________________________________________________________________________________________________________________
Degreeoffamilyinvolvement:______________________________________________________________________________
_________________________________________________________________________________________________________________
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AGAPÉBOARDINGSCHOOL
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MedicalInformation
Pleaselistallwhohaveexaminedortreatedyourchild:(Physicians,Psychiatrist,Psychologist,etc.)
Name:___________________________________________ NatureofServices:__________________________________
Address:________________________________________________________Date(mm/yy):_____________Age:________
Medications:______________________________________________________________________Currentlytaking?Y/N
DoctorPrescribing:______________________ReasonforPrescribing:________________________________________
Reasonfordiscontinuing/side-effects:_____________________________________________________________________
Ifyouansweredyestoanyoftheabove,pleaseexplain:_________________________________________________
_________________________________________________________________________________________________________________
Pleaselistanyotherdiagnosedmedicalconditionandthedateofdiagnosis:_________________________
_________________________________________________________________________________________________________________
Pleaselistanyallergies:_____________________________________________________________________________________
Pastorrecenttobacco,alcoholordruguse?Y/NPleaseexplain:______________________________________
_________________________________________________________________________________________________________________
Familyhistoryofsubstanceabuse:_________________________________________________________________________
_________________________________________________________________________________________________________________
Pleasecheckanyofthefollowingconditionsthatapplytoyourchild:
❑ Childhooddiseases ❑ Headache ❑ Seizures❑ Sinus ❑ Thyroid ❑ Pneumonia❑ Asthma ❑ Emphysema ❑ Tuberculosis❑ Heartattack ❑ Enlargedheart ❑ Valvedisease❑ HeartMurmur ❑ Highbloodpressure ❑ Emotionalproblems❑ Chestpain ❑ Gallbladderproblems ❑ Hepatitis❑ Heartburn ❑ Ulcers ❑ BowelDisease❑ Hemorrhoids ❑ Bloodystools ❑ Kidneystones❑ Bladderproblems ❑ Brokenbones ❑ Arthritis❑ Anemia ❑ Cancer ❑ Diabetes
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AGAPÉBOARDINGSCHOOL
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Toadequatelyunderstandtheparent/childrelationshipanditsimpactonthechild,itisveryimportantthatweknowofanyfamilytherapy.Pleaselistallpsychiatric,psychologicaland/ormarriageandfamilytherapythatthefamilymembershaveparticipatedin:NameofTherapist:______________________________________________ Datesseen:___________________________
Address:___________________________________________________ NatureofServices:__________________________
Whatwasaddressed:________________________________________________________________________________________
Frequency:__________________Familymemberswhoparticipated:_______________________________________
NameofTherapist:______________________________________________ Datesseen:___________________________
Address:___________________________________________________ NatureofServices:__________________________
Whatwasaddressed:________________________________________________________________________________________
Frequency:__________________Familymemberswhoparticipated:_______________________________________
NameofTherapist:______________________________________________ Datesseen:___________________________
Address:___________________________________________________ NatureofServices:__________________________
Whatwasaddressed:________________________________________________________________________________________
Frequency:__________________Familymemberswhoparticipated:_______________________________________
Pleaselistanypast/presentmedicalconcernsorconditionsoffamilymemberswhichmayaffect
yourchildorfamilyrelationships:__________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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AGAPÉBOARDINGSCHOOL
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AdditionalInformation
Havetherebeenanycircumstancesinthechild’slifewhichhavebeenhardforhimtoaccept?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Havetherebeenanydeathsoffamilyorfriendsthathavegreatlyimpactedyourchild?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Whatdoesyourchildbelievehiscurrentproblemtobe?
_________________________________________________________________________________________________________________
WhatareyourexpectationsofplacementatAgapéBoardingSchool?
_________________________________________________________________________________________________________________
Whatdoyouseeasyourchild’sestimatedstayatAgapéBoardingSchool?
_________________________________________________________________________________________________________________
Howdoyouplantobeinvolvedwithyourchild’sgrowthwhileatAgapéBoardingSchool?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Whatisyourchild’sperceptionofbeingplacedatAgapéBoardingSchool?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Whatdoyouseeyourchild’sandyourfamily’sgoalofsendinghimtoAgapéBoardingSchool?
_________________________________________________________________________________________________________________
Pleaseattachanyadditionalinformationthatyouthinkwillbehelpfulinunderstandingyourchild’scurrentsituation.
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AGAPÉBOARDINGSCHOOL
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Whatareyourchild’sspecialneedsandstrengthsinthefollowingareas?
Physical
Needs:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Strengths:_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Familial
Needs:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Strengths:_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Educational
Needs:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Strengths:_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Spiritual
Needs:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Strengths:_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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Social
Needs:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Strengths:_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Psychological
Needs:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Strengths:_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
EducationalHistory
Pleasedescribeyourchild’sperformance(grades,relationshipwithteachers,behavior,etc.):
Elementaryschool:___________________________________________________________________________________________
_________________________________________________________________________________________________________________
JuniorHigh:___________________________________________________________________________________________________
_________________________________________________________________________________________________________________
HighSchool:__________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Hasyourchildhaddifficultiesinschool?Y/N Ifyes,pleaseexplain:________________________________
_________________________________________________________________________________________________________________
HasyourchildhadanIEP(IndividualizedEducationPlan)orspecialeducationplacement?Y/N
Ifyes,pleaseexplain:________________________________________________________________________________________
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AGAPÉBOARDINGSCHOOL
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HasyourchildbeendiagnosedwithADD,ADHD,ODDorotherdiagnosis?Y/NIfyes,pleaselist:
_________________________________________________________________________________________________________________
Doesyourchildhavepooreyesight,hearingloss,speechimpediment,etc?Y/NIfyes,please
explain:_______________________________________________________________________________________________________
Hasyourchildeverrepeatedgrades?Y/N Ifyes,whichgrades?________________________________
Hasyourchildeverbeensuspendedorexpelled?Y/N Ifyes,when?_________________________
Pleaseexplain:________________________________________________________________________________________________
_________________________________________________________________________________________________________________
NameofSchoolsAttended Grade Year ReasonforLeaving
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Nameofcurrentschool:_______________________________________________ Phone:________________________
Address:______________________________________City:________________________State:_______Zip:______________
CurrentGrade:____________ StillAttending?Y/N Lastgradecompleted:_______________
Whatdoyouperceiveasyourchild’scurrentacademicneeds?__________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Youarenowreadytosubmityourapplication!Youcansubmityourapplicationbyfax,email,ormail.
_________________________________________________________________________________________________________________
AgapéBoardingSchool12998E.1400Rd.●Stockton,MO65785Office:417-276-7215●Fax:417-276-7217
Email:[email protected]
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AGAPÉBOARDINGSCHOOL
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MedicalDisclosureAgapéBoardingSchoolisaprivateChristianboardingschoolanddoesnotacceptanyfederalorstatefunds.Assuch,weareexemptfromhavingtoaccommodateanystudentregardlessofdisabilityandwillonlyacceptstudentsthatwecan,inourdiscretion,safelyandappropriatelyhouse,carefor,andministertowhileconsideringourlegitimateandvitalinterestinprotectingthehealthandsafetyofthestudentsandemployeesatAgapé.Therefore,itisthepolicyofAgapéBoardingSchooltonotadmitstudentswithcommunicablediseasesrequiringongoingmedicalorotherspecialsupport,andwewillconsideronacase-by-casebasisanycurrentorpotentialstudentswithmedicalconditionsordisabilitiesrequiringongoingmedicalorotherspecialsupport.
FinancialInformationEffectiveAugust1,2018
Agapé Boarding School strives to deliver the best possible training, both spiritually andeducationally, at the most reasonable price possible. Tuition and fees are geared to cover theregularoperationalexpensesoftheprogram.WeurgeparentsandotherstoconsiderthatAgapéBoardingSchool,asaministryofAgapeBaptistChurch,isexemptfromfederalincometaxundersection501C (3A)of the InternalRevenueCode as anorganizationdescribed in section501C(3A); therefore, any donated cash and/or property may be deducted from the donor’s federalincometax.Tuitionis$3,250permonth,foratotalof$39,000forayear.Tuitionincludesroomandboard.Inaddition,parentsareresponsibleforenrollmentfeesof$2,750whichmustbepaidonthedateofthestudent’sarrival.
Totalamountdueonstudent’sarrivalTuition:$3,250.00
EnrollmentFees:$2,000.00
Uniformandstartupitems:$750.00
*Student Account: $150.00
TotalDue:$6,150.00---($6000.00-Non-refundable)
Subsequentmonthly tuition payments of $3,250 are due as determinedby the enrollment dateandconfirmedbythefinanceofficeatenrollment.Pleaseplanforyourpaymenttoarrivenolaterthantheduedateasthereisno“graceperiod.”Onceanaccountbecomes30dayspastdue,aletterwill be sent to the parent or guardian tomake the account current. If the account is notmadecurrentwithin15daysofthatletter,thestudentwillbedischargedandsenthomeattheparent’sexpense.If a parent withdraws a student before the contract is up or if the student is withdrawn forfinancial reasons as listed above, there will be a $3,500 early termination fee added to thestudent’sbill.IfAgapéexpelsastudentfornon-financialreasonsthenthisfeedoesnotapply.