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: [email protected]
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: [email protected]
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
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dental exaMination
/ /Dental Check-Up
*OFFICE USE ONLY (Rev. 2010)
Preschool: Entry DateElementary: Entry DateIntermediate/Middle: Entry DateHigh: Entry Date
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FemaleMale
/ // // // /
PHySician’S exaMination code: n-noRMal; a-abnoRMal; c-coRRected; R-Receiving caRe
Date
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Wei
ght
Gra
de
Hei
ght
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miti
es
Scol
iosi
s
Bloo
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essu
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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
es)
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