Henderson Private School at Church by New Song Christian Academy

Student Information

Student's Name

First Name*

Last Name*

Nick Name

D.O.B.*

Gender
MaleFemale

New StudentReturning Student

Add a second student
Yes

Student's Name

First Name

Last Name

Nick Name

D.O.B.

New StudentReturning Student

Gender
MaleFemale

Class Enrolling for:

3 year old classes (Tues/Thu, 8:30am-12:30pm)4 year old classes (Mon/Wed/Fri, 8:30am-1:30pm)Junior Kindergarten (Mon-Fri, 8:30am-2:30pm)Kindergarten (Mon-Fr, 8:30am-2:30pm)

Add a third student
Yes

Student's Name

First Name

Last Name

Nick Name

D.O.B.

New StudentReturning Student

Gender
MaleFemale

Class Enrolling for:

3 year old classes (Tues/Thu, 8:30am-12:30pm)4 year old classes (Mon/Wed/Fri, 8:30am-1:30pm)Junior Kindergarten (Mon-Fri, 8:30am-2:30pm)Kindergarten (Mon-Fr, 8:30am-2:30pm)

Parent Information

Parent/Guardian Name

First Name*

Last Name*

Email*

Home Info

Parent/Guardian Name #2

First Name*

Last Name*

Email*

Home Info

Authorized Student Pick-up

In the event of an emergency, additional persons may be authorized to remove the child from the facility. We will not release a child into the care of anyone who is not listed on this form as either a parent/guardian or an emergency contact. Photo identification will be required from anyone listed.

Emergency Contact 1*

Emergency Contact 2*

Emergency Contact 3

Emergency Contact 4

Primary Care Physician*

Dentist*

Have Alergies*
YesNo

Please list any allergies or other health problems that we should be aware of *

Permission & Consent

Consent for Medical Treatment

In an emergency, New Song Christian Academy has my permission to call an ambulance or take
my child to any available physician or hospital at my expense. *
YesNo

In an emergency my child may receive first aid *
YesNo

In an emergency New Song Christian Academy has my permission to call *

and, if necessary, I give my consent to any doctor or hospital to administer medical or surgical
treatment and care for my child at my expense: *

Medication Release

Are you requesting any medication to be administered at/by school? *
YesNo

A completed medication authorization must be on file in the student's records. Please see the Academy Director for
details.

Permission & Consent

NAC 372.2(a) Consulting with Physicians or registered nurses regarding the health of the child:

Parent or guardian agrees for provider to consult with a nurse or physician in regards to child(ren)'s health as needed for
his/her clarification. In the event that we should have questions regarding the health of any child we may contact one, or
more. of the following sources for information:

Child's doctor*

Hospital

Southern Nevada Health District (702)759-1301

NRS 178

I am aware that I have the right to request and review any complaints the facility has received within the last 12 months of
my child's(ren's) enrollment.

Permission to release information

I understand that the time my child, named below, is in the facility that the director may be asked
for information regarding my child. *

YesNo

Child's Name

Photographic Release

As a parent or guardian of this student, I hereby consent to the use of photographs/audio visual material taken during the
course of the school year for publicity, promotional and/or educational purposes (including publications, presentations, or
broadcast via newspaper, internet, such as Facebook or school website, or other media sources). Only first names and
possible last initials (in the event of two or more children with the same first name) may be displayed with the photograph.
I do this with full knowledge and consent and waive all claims for compensation for use or damages.

YesNo

Field Trip Permit

I understand that during the year my child may take part in field trips and educational excursions, either by private car
(parenst take the child) or on foot. I further understand that my child will be chaperoned by a responsible adult at all times
while away from the facility. Should any accident occur while my child is away from the facility on the aforementioned trip,
I shall not hold the child's caretaker, members of the New Song Christian Academy facility or New Song Church and its
employees, nor any participating adult responsible.

YesNo

Policies and Procedures Agreement

I have read the Academy policies and procedures packet and agree to abide by the policies and procedures set forth
within.

I agree to the policies

Who will responsible for Payment? This is the person who will receive the tuition invoices each month.

Payor

Payor Address

Payment options

Automatic monthly invoicesPrepay in full (5% discount)

Payment Terms & Conditions

Enrollment is contingent upon receipt of the complete registration packet and payment of the applicable registration fee, both of which must be received before the first day of school. Tuition will be paid in nine (9) equal monthly installments via direct debit from a nominated savings or checking account, the first installment to be received by 09/01/2019 and the final by 05/01/2020. Any payment returned by a financial institution issued to New Song Christian Academy will result in the assessment of a per payment service charge against the issuer’s account (or against the account of the student on whose behalf a third party payment was made). The returned payment service charge, as authorized by Nevada state law (NRS 597.960) is $25.

Late Fees

Tuition and fees (fees include, but are not limited to, any registration, program or supply fees) are due in full by the dates specified in your tuition agreement and/or in the registration form of that activity. Tuition or fees that are past due 15 days will incur a late fee of $25.

I agree that all the answers I gave are accurate

Signature*

Student Information

Parent Information

Authorized Student Pick-up

Permission & Consent

Permission & Consent

NRS 178

Permission to release information

Photographic Release

Field Trip Permit

Policies and Procedures Agreement

Payment Terms & Conditions

Late Fees

Forms