ENROLLMENTAPPLICATION

2013 - 2014

Page 1 of 3 CONDUCT AND DISCIPLINE 09-10.doc  

 

StatementofFaith    

Dear KLD Students and Parents,  

The KLD leadership wishes to be clear in conveying our belief and our heart for God. We depend on the Holy Spirit to lead, rather than on fleshly promotion (Exodus 13:21). Acknowledging that fact, we stand firmly united in our belief in the Father; therefore we expect all those who work for us to participate in the carrying out of the mission of the KLD Youth Ministries.  

1. The Bible is the inspired, only infallible Word of God. ( II Peter 1:18,21)  

2. God eternally exist as the Father, Son and Holy Ghost. (2 Corinthians 13:14)  

3. JESUS CHRIST is the only begotten SON of the FATHER (John3:16), conceived of the HOLY SPIRIT (Matt. 1:20), and born of a virgin. That JESUS CHRIST was crucified, buried, and raised from the dead; that He ascended to heaven and is seated at the right hand of the Father as the intercessor. (Acts 2:23-33)

 4. Salvation comes through Jesus Christ alone, to whom we must respond with repentance, faith,

and obedience. Through Christ we come into a right relationship with God, our sins are forgiven, and we receive eternal life. (John 3:16; 16:7-11; Rom.10:13; Eph.2:5,8)

 5. That those who repent and believe should be baptized with water as a symbol of baptism

with the Spirit, cleansing from sin, and commitment to Christ. (Acts 2:38; 4:10-12; 8:16; 10:47-48; 19:3-6) That (Matt 3:11; Acts 1:4-8) the true believer receives the Holy Spirit and is baptized into the Body of Christ at conversion, that the Holy Spirit indwells every believer in and is an abiding helper, teacher, gift- giver, and guide. The Holy Spirit, by whose in- dwelling the believer is enabled to live a holy life, to witness and work for the Lord Jesus Christ ,which is the standard of living that God has for His people and that it must be sought and activated by faith. (Hebrews 12:14),

 6. God has called us to be and to make disciples of Jesus Christ and to be God's agents of love

and reconciliation in the world. Love is more important than the most spectacular gifts, and without love all exercise of spiritual gifts is worthless.

 7. Divine healing through faith in the Lord Jesus Christ is possible and achievable. Therefore we

also minister to those who are broken-hearted and troubled in mind. (Gal 6:1)  

8. God concerns Himself mercifully in the affairs of men. He hears and answers prayer. We believe in the interceding in prayer to Him for all men. (I Tim 2:1-3)

 9. PRAISE and WORSHIP to God is acceptable and worthy of all His believers. (Psalm 149:1)

 10. We believe in the personal return of Jesus Christ, in the resurrection of the dead, in God's

judgment of all persons with perfect justice and mercy, and in eternal reward and punishment. Ultimately, Christ's kingdom will be victorious over all evil, and the faithful will reign with him in eternal life. (Rev 22:12 – 21)

 

 Student Acknowledgement: Date:

   Parent Acknowledgement Date:

 

 

The future empowered…one life at a time 3700 NORTH COURTENAY PARKWAY, MERRITT ISLAND, FL 32953, ~ Telephone (321) 454-7333

 Fee Schedule

 Estimated Charges for 2013-2014 School Year After school care $ 5.00 Per day Academic Learning Lab $ 55.00 Per session

Est / End of Year Event Fee $ 80.00 If Scheduled

Late Enrollment Fee $ 125.00 After May 1st

New Student Fee $ 500.00  Application Fee $ 250.00  Books / Supplies / Curriculum $ 310.00  ID Badges $ 50.00  Return Check Fee $ 30.00  Speech Therapy - Group Session $ - May be available through County

Base Tuition $ 6,495.00  The Base tuition of $6,495.00 may increase if additional aid (as stated below)is required.

Individual Therapy $ 35.00 Per Session

Group Educational Therapy $ 20.00 Per Session

Charges that Vary Uniform Fees Pants/Skirt/Shorts @ $15.00 Polo Shirts @ $15.00 Field Trips Depends on itinerary Summer School Classes Varies by class WHEN AVAILABLE

 New students must pay all upfront fees within two weeks of acceptance. Theses fees are non-refundable. All tuition is due prior to school starting unless other arrangements have been made through the Registrar’s office. Tuition insurance may be required for new families and may be waved by the Registrar’s office for returning students.

 Returning students pay all re-enrollment deposits a n n u a l l y . This non-refundable deposit reserves a student's place for the upcoming school year, subject to the student's satisfactory completion of the current year.

 Families may choose between three tuition payment plans: one annual payment, two semester payments, or 10 monthly payments. A finance charge of 12% applies to the semester and monthly payment plans. Financing is also available through outside sources; please see Mrs. Deaton for details.

 Tuition does not include charges for, special events, field trips, and graduations. These fees and similar charges vary by grade level and will be charged where applicable.

 

 Student Name: Amount Due:

 Parent Acknowledgement by Signature:

               

KLD Youth Ministries, Inc. a registered 501(c)3 organization.

Confidential Page 1 of 4 Last Revised: 3/31/2009  

 Application Fee: ________

 

Date Submitted:  

_________  

Check # ________________  

School Year Applying for:  

 

Today’s Date

Student’s Full Legal Name  Date of Birth Male Female S tuden t s SS#

Address

City Zip

Mailing Address (if different)  City ______________________________________________________Zip _________________________

Phone (Home) Phone (Cell)

Email

School Presently Attending Grade:

Please list the names of other siblings that will be attending the KLD Learning Center?___________      

Does the student reside with Parent? ☐ Yes ☐ No Who: ____________________________________ Are Parents � Married ☐Divorced ☐ Widowed ☐Separated ☐Single ☐Remarried Please provide information on whom the student resides with: (supporting documents may be required)

Father’s Name Occupation

SS#:

Employer Work Phone

Mother’s Name Occupation

SS#:        

Employer ______________________________________ Work Phone __________________________

Step Parent’s Name (if applicable) ______________________________________________________

If not any of the above, with whom does the student reside? ____________________________________  

 

Who has authority to pick up your child?    ☐  Father      ☐  Mother    ☐  Step  Parent      ☐  Other  

Father’s Cell _____________________________________ Mother’s Cell _________________________

Step Parent’s Name _____________________________________ Cell __________________________

Other’s Name _____________________________________ Other’s Cell _________________________

Other’s Relationship to student? ________________________________________________________

 

Student Information

Parent Information

Confidential Page 2 of 4 Last Revised: 3/31/2009  

Has your child been enrolled in or recommended for any of the following special classes ☐ Learning Disability ☐ Speech Therapy ☐ Physically Handicapped

Please explain any above checked items    

Has your child had any problems with discipline in a previous school? ☐ Yes ☐ No

If yes, please explain    

Child’s Primary Physician Name: Phone:

Does your child have any unusual or chronic health issues? ☐ Yes ☐ No

Please list any conditions that may include major surgeries, seizures, asthma, diabetes, etc.        

Please list any medication (s) prescribed for the above listed condition (s): We require that parents notify the school of any changes in medication by the following school day. 1.

 

2.

 Physician  

Physician  

Please list any mental health diagnosis(es)(Anxiety, Depression, Add/ADHD):  

Psycho-social evaluations must accompany this application if the above is filled out. Please see Administrator for further information. As well, please provide a list of medication (s) prescribed for the above listed diagnosis (es).

 

1. Physician

2. Physician  

Do you authorize health screening for your student? Please initial your response. Yes No

 

Do you authorize emergency medical treatment? Please initial your response. Yes No

   

Are you financially able to meet the monthly tuition requirements? ☐ Yes ☐ No

Comments  

What do you see as your part in your child’s education?      

What is your practicing religion?  

Is a language other than English used in the home? If yes, indicate language

I/We certify that the above information is complete and accurate. I/We understand that any information found to be inaccurate may be considered grounds for my/our child’s dismissal from KLD.          Signature of Father Date

 

     Signature of Mother Date

 

Medical / Health Information  

Agreement

Confidential Page 3 of 4 Last Revised: 3/31/2009  

   

Gender: ☐ Female � Male  

Race: � American Indian or Alaskan Native � Asian or Pacific Islander � Black � White � Hispanic � Combination of Two or More Races (if checked supply the code from the attached list): Code:

 Person with a disability: � Yes If yes, do you need accommodations during the application for admission process? � Yes If yes, please describe the accommodations needed.

 

Person who is an English language learner or limited English proficient: ☐ Yes If yes, do you need language assistance during the application for admission process? ☐ Yes If yes, please describe the assistance needed.

 

VOLUNTARY INFORMATION SECTION

The information requested in this section is not required for admission. Submission of the information is entirely voluntary. Information submitted voluntarily by the applicant will not affect the applicant’s admission to the school. The information, if supplied, will be used for monitoring equal educational opportunity in this school and used for grant information only. In addition, note that applicants with disabilities may voluntarily self-identify for the purpose of requesting reasonable accommodations during the entire application and admission process. Applicants who are English language learners or limited English proficient may voluntarily self-identify for the purpose of receiving interpretive services during the entire application and admission process.

NON DISCRIMINATION POLICY

The education branch of the KLD Youth Ministries Inc admits students of any race, color, national or ethnic origin, disability, sex or age to all the rights, privileges, programs, and activities gen- erally afforded or made available to students at the school. It does not discriminate on the basis of race, color, national or ethnic origin, disability, sex or age in administration of its educational or admissions policies, scholarship and other programs or employment.

Confidential Page 4 of 4 Last Revised: 3/31/2009  

 

  Not Hispanic or Latino

Hispanic or Latino

One race

White 01 33

Black or African American 02 34

Asian 03 35

American Indian or Alaska Native 04 36

Native Hawaiian or Other Pacific Islander 05 37

Combination of Two Races

White & Black or African American 06 38

White & Asian 07 39

White & American Indian or Alaska Native 08 40

White & Native Hawaiian or Other Pacific Islander 09 41

Black or African American & Asian 10 42

Black or African American & American Indian or Alaska Native 11 43

Black or African American & Native Hawaiian or Other Pacific Islander 12 44

Asian & American Indian or Alaska Native 13 45

Asian & Native Hawaiian or Other Pacific Islander 14 46

American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander 15 47

Combination of Three Races

White & Black or African American & Asian 16 48

White & Black or African American & American Indian or Alaska Native 17 49

White & Black or African American & Native Hawaiian or Other Pacific Islander 18 50

White & Asian & American Indian or Alaska Native 19 51

White & Asian & Native Hawaiian or Other Pacific Islander 20 52

White & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander 21 53

Black or African American & Asian & Native Hawaiian or Other Pacific Islander 22 54

Black or African American & Asian & American Indian or Alaska Native 23 55

Black or African American & Native Hawaiian or Other Pacific Islander & American Indian or Alaska Native

24 56

Asian & Native Hawaiian or Other Pacific Islander & American Indian or Alaska Native 25 57

Combination of Four Races

White & Black or African American & Asian & American Indian or Alaska Native 26 58

White & Black or African American & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

27 59

White & Asian & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

28 60

White & Black or African American & Asian & Native Hawaiian or Other Pacific Islander 29 61

Black or African American & Asian & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

30 62

Combination of Five Races

White & Black or African American & Asian & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

31 63

Revised on: 5/10/2010 1:08:00 PMPage 1 of 2  

   

STUDENT AGREEMENT STATEMENT    

PLEASE READ CAREFULLY and place your initials beside each statement to indicate your agreement.

 In making this application, I/We agree that:

 1. We will accept the challenge to “train up a child in the way he should go” and state that this

training will be carried on in the home. We shall place our trust in KLD to extend that training more completely.

 2. We have read the Parent/Student Handbook and agree to abide by all standards, procedures,

and regulations therein.  

3. We will pray for the school’s staff.  

4. If for any reason our child does not respond favorably to the school’s standards, guidelines, or expectations, which causes us to withdraw him/her we understand that all fees up to and including 30 days from the time of written notification of withdraw are our responsibility. Also, if your child is enrolled for ten or more days in a semester you are responsible for the entire semester’s fees. Tuition is calculated on the basis of the entire year; therefore, no reduction can be made for vacations or school holidays. Tuition is not based upon daily attendance. Should a student transfer before the end of the school year, the parents are responsible for the monthly installments through the current month enrolled. In addition, if a re-enrolled student withdraws after June 1, there is a $250 withdrawal fee. Fees, discounts, and incidental charges are neither prorated nor refundable and cannot be allocated to the accounts of siblings. Also, if any student is on a scholarship withdraws throughout the year they must pay the prorated scholarship amount.

 5. We will pay all tuition and fees promptly and according to school policies. Late fees will be

th

added to payments received after the 10 th

of the month and again after the 20 of the month. When a tuition account is two months in arrears, the student(s) may be withdrawn from school, and records will be withheld until required payments are made in full.

 6. If our student is withdrawn, we will notify the school office in writing at least 30 days

prior to the planned withdraw date.  

7. Our child (ren) will participate on scheduled field trips and other school activities.  

8. We understand that KLD Learning Center does not provide voluntary medical insurance coverage for students. Should a student become injured on the premises or during a school sponsored event, the student’s family insurance is the primary carrier.

 9. We will promote the spirit of unity within the school by following the Matthew 18

 

principle.If a problem arises, we will first contact the school personnel who can help (rather than those not involved). We will follow the proper chain of command when necessary until the problem is resolved. The parties to this agreement adhere to Christian principles and believe that the Bible commands them to make every effort to live at peace and to resolve disputes with each other in private or within the Christian community in conformity with the biblical injunctions of I Corinthians 6:1-8, Matthew 5:23-24, and Matthew 18:15-20. Therefore, the parties agree that any claim or disputes arising out of or related to this agreement including, but not limited to, claims arising from statute, ordinance, regulation, case law or any other source shall be settled by biblical based mediation. If resolution of the dispute and reconciliation do not result from such effort, the matter shall then be submitted to an independent and objective arbitrator for binding arbitration. The parties agree that the mediation and arbitration process will be conducted in accordance with the “Rules of Procedure for Christian Conciliation” contained in the Peacemaker Ministries booklet, Guidelines for Christian Conciliation, (http://www.peacemaker.net) which both parties will have had opportunity to review. The parties agree that these methods shall be the sole remedy for any controversy or claim arising out of this agreement and expressly waive their right to file a lawsuit against one another in any civil court for such disputes except to enforce a legally binding arbitration decision. Each party, regardless of the outcome of the matter, agrees to bear one-half of the fees and costs of the arbitrator and any other arbitration expense. The parties to this agreement have had an opportunity to consult legal counsel before signing this agreement.

 10. I give permission for my child(ren) to be photographed and/or videotaped. I understand

that these may be used on the KLD website or in other promotional materials produced for the school or the KLD Youth Ministries; however full names will not be disclosed.

 11. Recommendation for admission of the applicant is at the discretion of the KLD

Administration. Final approval of admission is determined by the KLD Admissions Committee.

 12. We have carefully read the above guidelines and have accurately completed all

items outlined in this application, and we agree to uphold all guidelines as part of the PI family.

       Father’s Signature Date  _________________________________________________________________ Mother’s Signature Date

 

 _________________________________________________________________ Student’s Signature Dat

 

 

                 2013-­‐2014  KLD  School  Calendar  

   

Wednesday   August  7   Teachers  Report  Monday   August  19   Students  Report    

 Friday   August  30   Sign  McKay  Checks  Monday   September  2   Labor  Day/Holiday  for  All  Monday   September  9   Professional  Development  

/Day/No  school  Friday   September  13   Interims  Posted  &  Issued    Friday   October  4   Professional  Development  Day  

Wednesday   October  16   First  9  weeks  Ends  Tuesday   October  25   Report  Cards  Issued  Friday   November  1   Sign  McKay  Checks  Monday   November  11   Veterans  Day/Holiday  for  All  Friday   November  15   Second  Interim  Ends  Monday   November  18   Interim  Posted  &  Issued    Friday-­‐Monday   November  23-­‐25   Thanksgiving  Holiday  Friday   December  20   End  of  First  Semester  Saturday   December  21   Winter  Vacation  Begins  Monday    

January  6   Last  Day  of  Winter  Vacation  Thursday   January  9   Second  Semester  Begins  Thursday   January  16   MLK  Jr.  Birthday/Holiday  for  All  Friday   January  17   Report  Cards  Issued  Monday   February  3   Sign  McKay  Checks  Sunday   February  9   Third  Interim  Ends  Friday   February  14   Interims  Posted  &  Issued  Thursday   February  20   Presidents  Day/Holiday  for  All  Friday   March  14   Third  9  weeks  Ends  Monday   March  24   Report  Cards  Issued  Monday-­‐Friday   March  24-­‐28   Spring  Vacation  Wednesday   April  2   Sign  McKay  Checks  Friday   April  6   Holiday  for  All  Thursday   April  24   Forth  Interim  Ends  Tuesday   April  29   Interims  Posted  &  Issued  Thursday   May  29   End  of  Second  Semester  Monday   May  26   Memorial  Day/Holiday  for  Staff  Tuesday   June  3   Last  Day  for  Teachers  Friday   June  13   Report  Cards  Issued  

           

� During  the  school  year,  emergency  days  may  be  taken  for  hurricanes  or  other  related  causes.    This  may  cause  make-­‐up  days  to  be  scheduled.  

� Other  adjustments  or  changes  to  the  School  Calendar  may  be  done  with  notice  to  parents.  

 

KLD Field Trip Permission Slip  Periodically, throughout the 2013-2012 school year KLD will take field trips, to further enhance your child’s education, this form is meant to provide your permission for your child to attend such trips over the school year. This form will be kept in your child’s file.  I give my permission for to attend fieldtrips

with KLD that may be driven by other Staff, Parents, or Chaperones.    I hereby grant authorization to the KLD or its representatives, to provide emergency medical attention to the above said student in the event of a medical emergency while away on KLD field trips.  I also hereby agree to hold harmless KLD and its representatives, for any and all actions, damages, or liabilities arising out of the negligent acts of others, in regards to any accident or sickness or treatment thereof incurred by my said KLD student during or from KLD field trips.  It is necessary that this form remain on file for every student going on any field trip throughout the year with KLD Learning Center (KLD High School, KLD Junior High School, KLD Elementary, or KLD Academy). No student will be allowed to leave the fieldtrip site or KLD property without parental/guardian permission.

Students allergies, if any___________________________________________

Parent/Guardian

Address

Phone

Signature (Please bring photo I.D.)

   STATE OF FLORIDA COUNTY OF BREVARD  The foregoing instrument was acknowledged before me this day of

, , by .      

Notary Public  Personally Known , OR Produced Identification    Type of Identification Produced

_____________________________________________________________________________________________