Ark of Safety Christian Academy

“Building Powerful Witnesses to the World”

86-120 Farrington Hwy., Suite 109A-110 Waianae, HI 96792

Phone#: (808) 696-8928 Fax#: (808) 696-1299

Application for Admission Grades: Kindergarten – 8th 2016-2017

Please read the entire instructions carefully

Application to grades K-8th

Kindergarten is an entry level to Ark of Safety Christian Academy – Upper Grades

We accept applications from Ark of Safety Christian Academy Preschool students as well as other age-eligible

applicants. There are usually many more qualified applicants than spaces; competition is keen and admission to

our upper grades is neither automatic nor guaranteed.

Age-eligible applicants must be five years of age by July 31st of that starting school year.

Application Fees

A non-refundable registration fee of $100 is due upon submission of application. Applications are accepted on

a first come, first served basis, and is necessary to reserve a space for the student.

A non-refundable, annual Smart Tuition Fee $50 (Financial Institution). June 1, 2016

A non-refundable Comprehensive Fee of $400 (Student Kit-Literacy, Work, On-line). June 1, 2016

Required Documents

o Copy of your child’s birth certificate

o Completed Common Teacher Reference Form

o Completed Pastor or Ministry Reference Report

o Copy of most recent progress report or report card

o Student Health Record Form 14 completed by child’s primary care physician to include updated immunization

and tuberculosis (TB) records

o Parent/Caregiver TB clearance

Application Deadline

The completed application, application fee, and ALL required documents are due by May 15, 2016

Please follow up with your child’s teacher(s) and pastor/ministry leader to ensure references are sent in by the

due date.

Only completed applications with ALL required documents will be processed. Applicants whose applications are

incomplete will not be processed or scheduled for testing until completed.

Testing

An individual observation and academic testing session shall be scheduled

It is essential to make every effort to attend the scheduled test session(s); postponing the test session will delay

the processing of your child’s application

Notification and Other Enrollment Information

First Round applicants are notified of a decision at the beginning of June

ARK OF SAFETY CHRISTIAN ACADEMY 2016-2017 SCHOOL YEAR APPLICATION FOR ADMISSION

___________________________________________________________________________-______-__________________________________ Student Name Social Security Number

Male□ Female□ Age: ______________ Birth Date:

Ethnicity: □African American □Asian □Caucasian □Hispanic □Native Hawaiian □Other

Current Address City State Zip Physical Disabilities: Special Needs: FAMILY INFORMATION Father/Guardian ( ) ( ) Home Phone Number Cell Number E-Mail Place of Employment Position Mother/Guardian ( ) ( ) Home Phone Number Cell Number E-Mail Place of Employment Position Language spoken at home: ______________________________________ The following information will be kept confidential. (This information is needed when AOS applies for grants and scholarship awards.)

Family Size:________________________________ Annual Household Income: □ $30,000 or less □ $30,000-39,999 □ $40,000-49,999 □ $50,000+

Other children’s names and grades (circle if enrolled at AOSCA):

CHURCH INFORMATION

Church Member: □Yes □No

Church Name Pastor Address City State Zip Code SCHOLASTIC INFORMATION Previous/Present School Name Phone Number Address City State Zip Code Elementary Level Jr. High Level High School Level K 1 2 3 4 5 6 7 8 9 10 11 12

BUILDING STUDENTS TO BE POWERFUL WITNESSESS TO THE WORLD PHONE: 808-696-8928 85-179 Waianae Valley Road, Hawaii 96792

Common Teacher Reference (Grades 2-8)

Ark of Safety Christian Academy

TO THE PARENT OR GUARDIAN: Complete and sign the following statement of consent to the reference giver, with full awareness that the information on this form is strictly confidential, cannot be shared with you, and is only for admission purposes. Include a stamped envelope addressed to Ark of Safety Christian Academy.

I hereby give my permission to release the information that is requested on this

form regarding my child, for the purpose of admission to Ark of Safety

Christian Academy.

Signature: Date:

TO THE TEACHER: Ark of Safety Christian Academy sincerely appreciates your willingness to complete this form on behalf of the applicant. The parent/guardian is aware that any information you supply will be held in strict confidence.

Do not return this form to the parent/guardian after completion. Fax, email, or mail it to the school directly, as soon as possible after receipt of this form.

Applicant’s Legal Last Name Applicant’s Legal First Name Grade Applying

Class Level: m Accelerated m High m Average m Low m Heterogeneous Self-contained: m Yes m No

Subject: m Math m English Grade: m 2nd m 3rd m 4th m 5th m 6th m 7th m 8th

Academic Qualities

Motivation (effort, drive) m Rare m Moderate m Maximum

Ability to work alone m Needs help frequently m Needs help occasionally m Works Well

Homestudy Habits m Never completes assignments m Completes assignments m Does more than expected

Participation in discussion m Contributes when called on m Volunteers occasionally m Joins in readily

Ability to express ideas orally m Has some difficulty m Good m Exceptionally good

Use of time m Poor m Average m Excellent

Organization of work m Poor m Average m Excellent

Follows Directions m Needs much explanation m Needs occasional help m Responds quickly

Personal Qualities

Leadership potential m A follower m Occasionally seeks opportunities m Natural leader

Classroom conduct m Poor m Average m Excellent

Cooperates with adults m Rarely m Usually m Always

Personal/social adjustment m Relates poorly with others m Generally happy person; fluctuating relationships with peers

m Healthy self image; healthy peer relationships

Ability to work in a group m Rarely m Usually m Always

Consideration of others m Rarely m Usually m Always

Takes initiative m Rarely m Usually m Always

Fulfills responsibilities m Rarely m Usually m Always

Uses suggestions or corrections m Rarely m Usually m Always

Additional Questions

Have you ever had to make special accommodations or had to refer student for additional support services/needs?

Explain, if necessary:

Print Teacher’s Name Teacher Signature

School School Phone Date

Ark of Safety Christian Academy

85-179 Waianae Valley Road

Waianae, Hawaii 96792

Email: academy@aoshawaii.com

Ph: (808) 696-8928 Fax: (808) 696-1299 Website: www.aoshawaii.com

We appreciate additional observations about this applicant:

Pastor or Ministry Reference Report for Ark of Safety Christian Academy

TO THE PARENT OR GUARDIAN: Complete and sign the following statement of consent to the reference giver, with full awareness that the information on this form is strictly confidential, cannot be shared with you, and is only for admission purposes. Include a stamped envelope addressed to Ark of Safety Christian Academy.

I hereby give my permission to release the information that is requested on this

form regarding my child, for the purpose of admission to Ark of Safety

Christian Academy.

Signature: Date:

TO THE TEACHER: Ark of Safety Christian Academy sincerely appreciates your willingness to complete this form on behalf of the applicant. The parent/guardian is aware that any information you supply will be held in strict confidence.

Do not return this form to the parent/guardian after completion. Fax, email, or mail it to the school directly, as soon as possible after receipt of this form.

Applicant’s Legal Last Name Applicant’s Legal First Name

Pastor/Reference

Pastor/Reference Name Church/Organization (if applicable)

Position/Job Title at Organization (if applicable)

How long have you been involved with the applicant in this capacity?

Organization Street Address (if applicable) City

State ZIP Daytime Phone

Comments & Impressions

Please provide your personal comments and impressions regarding the applicant’s character:

Pastor/Reference Signature Date

Ark of Safety Christian Academy

85-179 Waianae Valley Road

Waianae, Hawaii 96792

Email: academy@aoshawaii.com

Ph: (808) 696-8928 Fax: (808) 696-1299 Website: www.aoshawaii.com

Student Address Label

Medical StatuS

Department of EducationStudent’S HealtH RecoRd

Name

Birthdate

Parent’s Name

(Last) (First) (Middle Initial)

Month Day Year

Please complete the following sections (CHECK IF YES)

Date Read

Results (mm)

Physician, APRN, PA, or ClinicDate Given

LocationDate Results

tubeRculoSiS exaMination Mantoux teSt (intRadeRMal)

cHeSt x-Ray

/ // /

/ // /

dental exaMination

/ /Dental Check-Up

*OFFICE USE ONLY (Rev. 2010)

Preschool: Entry DateElementary: Entry DateIntermediate/Middle: Entry DateHigh: Entry Date

❑

❑

FemaleMale

/ // // // /

PHySician’S exaMination code: n-noRMal; a-abnoRMal; c-coRRected; R-Receiving caRe

Date

/ /

/ /

Wei

ght

Gra

de

Hei

ght

Extre

miti

es

Scol

iosi

s

Bloo

d Pr

essu

re

Skin

Abdo

men

Lung

sH

eart

Teet

h

Thro

atN

ose

Eyes

HearingVision

Ner

vous

Sy

stem

R. L. R. L. Ears

Nut

ritio

n Provider’s Stamp or Printed NameProvider’s Signature

Rev

iew

ed

Imm

uniz

atio

n R

ecor

d (C

heck

if Y

es)

Varicella Immunity

Secondary to Disease (DATE) C

ompl

eted

PP

D S

cree

ning

(C

heck

if Y

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See

Resu

lts B

elow

/ /

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BMI

Allergy (type) ❑ Cancer/Leukemia ❑ Hearing Problems ❑ Hypertension ❑ Seizures ❑ Vision Problem ❑Asthma ❑ Chronic Cough/Wheezing ❑ Heart Disease ❑ JRA Arthritis ❑ Sickle Cell Anemia ❑Behavioral Problems ❑ Diabetes ❑ Hemophilia ❑ Rheumatic Heart ❑ Skin Problems ❑

Physician, APRN, PA or Clinic

iMMunizationS (vaccineS, dateS given: MontH/day/yeaR) Type

Date / / / / / / / / / / / /Type

Date / / / / / / / / / / / /Type

Date / / / / / / / / / / / /Type

Date / / / / / / / / / / / /Type

Date / / / / / / / / / / / /Date

/ / / / / / Varicella / / / /Date / / / / Type

Date / / / / / / / / / / / /Type

Date / / / / / / / / / / / /

DTaP, DTP, DT, Tdap or Td

Polio (IPV or OPV)

Hib (Haemophilus influenzae type b )

Pneumococcal Conjugate

Hepatitis B

MMR

Hepatitis A

Other

Other

Allergies: (Mother/Legal Guardian) (Father/Legal Guardian)

Health History Comments: Include Referrals and Reports. Recommendation for significant findings. (Please Print)

STATE OF HAWAI‘I, DEPARTMENT OF EDUCATION, FORM 14, Rev. 4/13, RS 13-1114 (Rev. of RS 10-1369)

Signature & TitleDateDate Signature & Title