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 2017-2018

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 & Tuition 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 of $50 (Financial Institution) Due: June 1, 2017

A non-refundable Comprehensive Fee of $450 (Student Kit-Literacy, Work, On-line; collected by SmartTuition).

Due: June 1, 2017

Tuition Fee is $4,750/school year (or $475/month for 10 months; to be collected by SmartTuition).

Required Documentso 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

o Copy of Medical Insurance card

Application Deadline

The completed application, application fee, and ALL required documents are due by March 1, 2017

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 ACADEMY2017-2018 SCHOOL YEAR APPLICATION FOR ADMISSION

86-120 Farrington Hwy., Ste. #A109-A110Waianae, Hawaii 96792

Ph:(808)696-8928/Fax:(808)696-1299

___________________________________________________________________________-______-__________________________________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 LevelK 1 2 3 4 5 6 7 8 9 10 11 12

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

TOTHEPARENTORGUARDIAN:Complete and sign the following statement of consent to the reference giver, with fullawareness that the information on this form is strictly confidential, cannot be sharedwith you, and is only for admission purposes. Include a stamped envelopeaddressed 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:

TOTHETEACHER:

Ark of Safety Christian Academy sincerely appreciates your willingness tocomplete this form on behalf of the applicant. The parent/guardian is aware thatany 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 Size School Hours With Teacher Since (month/year)

Does your school issue report cards/progress reports? m Yes m No

Social and Emotional Behavior

Works cooperatively m Beginning m With teacher support m Growing Independence m Consistent & Independent

Works Independently m Beginning m With teacher support m Growing Independence m Consistent & Independent

Accepts Responsibility m Beginning m With teacher support m Growing Independence m Consistent & Independent

Is able to relate to adults m Beginning m With teacher support m Growing Independence m Consistent & Independent

Shows good attention span m Beginning m With teacher support m Growing Independence m Consistent & Independent

Work Habits and Attitudes

Shows initiative m Beginning m With teacher support m Growing Independence m Consistent & Independent

Listens attentively m Beginning m With teacher support m Growing Independence m Consistent & Independent

Follows directions m Beginning m With teacher support m Growing Independence m Consistent & Independent

Completes assigned tasks m Beginning m With teacher support m Growing Independence m Consistent & Independent

Cares for materials m Beginning m With teacher support m Growing Independence m Consistent & Independent

Shows an active interest in classroom activities m Beginning m With teacher support m Growing Independence m Consistent & Independent

Learning Readiness

Articulates appropriately for age m Beginning m With teacher support m Growing Independence m Consistent & Independent

Uses an adequate vocabulary m Beginning m With teacher support m Growing Independence m Consistent & Independent

Listens to and enjoys stories read m Beginning m With teacher support m Growing Independence m Consistent & Independent

Recalls specific story details m Beginning m With teacher support m Growing Independence m Consistent & Independent

Recalls main idea of a story m Beginning m With teacher support m Growing Independence m Consistent & Independent

Recognizes differences in size, shape and qty. m Beginning m With teacher support m Growing Independence m Consistent & Independent

Recognizes rhyming sounds m Beginning m With teacher support m Growing Independence m Consistent & Independent

Understands and uses number vocabulary m Beginning m With teacher support m Growing Independence m Consistent & Independent

Counts objects m Beginning m With teacher support m Growing Independence m Consistent & Independent

Small muscle coordination m Beginning m With teacher support m Growing Independence m Consistent & Independent

PLEASE COMPLETE QUESTIONS ON THE BACK SIDE

Print Teacher Name Teacher Signature

School School Phone Date

Ark of Safety Christian Academy85-179 Waianae Valley RoadWaianae, Hawaii 96792

Email: academy@aoshawaii.comPh: (808) 696-8928 Fax: (808) 696-1299 Website: www.aoshawaii.com

Common Teacher Reference (Grades K-1)

Ark of Safety Christian Academy

Common Teacher Reference (K-1), page 2Ark of Safety Christian Academy

Indicate which words best describe the child: (check all that apply)

m Passive m Vivacious m Good-humored

m Aggressive m Stubborn m Cheerful

m Insecure m Leader m Follower

m Shy m Other:

m Well-liked m Overactive m Sociable m Belligerent

m Self-centered m Nervous m Irritable m Persistent

m Easily Discouraged m Attention-getter m Aloof m Sullen

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

Explain, if necessary:

Are the parents/guardians cooperative and supportive of you?

Explain, if necessary:

Comments

We appreciate additional observations about this applicant:

m Highly m Usually m Sometimes m Rarely

Ark of Safety Christian Academy85-179 Waianae Valley RoadWaianae, Hawaii 96792

Email: academy@aoshawaii.comPh: (808) 696-8928 Fax: (808) 696-1299 Website: www.aoshawaii.com

Common Teacher Reference (Grades 2-8)

Ark of Safety Christian Academy

TOTHEPARENTORGUARDIAN:Com ple te and sign th e following state m e ntof conse ntto th e re fe re nce give r, with fullaware ne ssth atth e inform ation on th isform isstrictly confide ntial, cannotb e sh are dwith you, and isonly foradm ission purpose s. Include a stamped envelopeaddressed to Ark of Safety Christian Academy.

I h e re b y give m y pe rm ission to re le ase th e inform ation th atisre que ste d on th is

form re garding m y ch ild, forth e purpose of adm ission to Ark of Safe ty

Ch ristian Acade m y.

Signature: Date:

TOTHETEACHER:Ark of Safe ty Ch ristian Acade m y since re ly appre ciate syourw illingne sstocom ple te th isform on b e h alf of th e applicant. Th e pare nt/guardian isaw are th atany inform ation you supply w ill b e h e ld in strictconfide nce .

Do not return this form to the parent/guardian after completion. Fax, e m ail, orm ail itto th e sch ool dire ctly, assoon aspossib le afte rre ce iptof th isform .

Applicant’sLe gal LastNam e Applicant’sLe gal FirstNam e Grade Applying

ClassLe ve l: m Acce le rate d m High m Ave rage m Low m He te roge ne ous Se lf-containe d: m Y e s m No

Sub je ct: m Math m English Grade : m 2nd m 3rd m 4th m 5th m 6th m 7th m 8th

Academic Qualities

Motivation (e ffort, drive ) m Rare m Mode rate m Maxim um

Ab ility to w ork alone m Ne e dsh e lp fre que ntly m Ne e dsh e lp occasionally m W orksW e ll

Hom e study Hab its m Ne ve rcom ple te sassignm e nts m Com ple te sassignm e nts m Doe sm ore th an e xpe cte d

Participation in discussion m Contrib ute sw h e n calle d on m Volunte e rsoccasionally m Joinsin re adily

Ab ility to e xpre sside asorally m Hassom e difficulty m Good m Exce ptionally good

Use of tim e Poor m Ave rage m Exce lle nt

Organization of w ork Poor m Ave rage m Exce lle nt

Follow sDire ctions m Ne e dsm uch e xplanation m Ne e dsoccasional h e lp m Re spondsquickly

Personal Qualities

Le ade rsh ip pote ntial m A follow e r m Occasionally se e ksopportunitie s m Natural le ade r

Classroom conduct m Poor m Ave rage m Exce lle nt

Coope rate sw ith adults m Rare ly m Usually m Alw ays

Pe rsonal/social adjustm e nt m Re late spoorly w ith oth e rsm Ge ne rally h appy pe rson; fluctuatingre lationsh ipsw ith pe e rs

m He alth y se lf im age ; h e alth y pe e rre lationsh ips

Ab ility to w ork in a group m Rare ly m Usually m Alw ays

Conside ration of oth e rs m Rare ly m Usually m Alw ays

Take sinitiative m Rare ly m Usually m Alw ays

Fulfillsre sponsib ilitie s m Rare ly m Usually m Alw ays

Use ssugge stionsorcorre ctions m Rare ly m Usually m Alw ays

Additional Questions

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

Explain, if necessary:

PrintTe ach e r’sNam e Te ach e rSignature

Sch ool Sch ool Ph one Date

A rkof S afetyC hristian A cademy

85-179 Waianae Valley RoadWaianae, Hawaii 96792

Email: academy@aoshawaii.comPh: (808) 696-8928 Fax: (808) 696-1299 Website: www.aoshawaii.com

W e appre ciate additional ob se rvationsab outth isapplicant:

Pastor or Ministry Reference Reportfor Ark of Safety Christian Academy

TOTHEPARENTORGUARDIAN:C om p lete andsign the following statem entofconsentto the reference giver,w ith fullawarenessthatthe inform ation on thisform isstrictly confidential,cannotbe sharedwith you,andisonly for adm ission p urp oses.Include a stam pe d e nve lopeaddre sse d to Ark of Safe ty Ch ristian Acade m y.

Ihereby give m y p erm ission to release the inform ation thatisrequestedon this

form regarding m y child,for the p ur p ose ofadm ission to A r k ofSafety

C hristian A cadem y.

Signature : Date :

TOTHETEACHER:A r k ofSafety C hristian A cadem y sincerely ap p reciatesyour w illingnesstocom p lete thisform on behalfofthe ap p licant.T he p arent/guardian isaw are thatany inform ation you sup p ly w illbe held in strictconfidence.

Do notre turn th isform to th e pare nt/guardian afte rcom ple tion. Fax,em ail,orm ailitto the schooldirectly,assoon asp ossible after receip tofthisform .

A p p licant’sLeg alLastNam e A p p licant’sLeg alFirstNam e

Pastor/Re fe re nce

P astor/Refer ence Nam e C hur ch/O r g anization (ifap p licable)

P osition/Job T itle atO r g anization (ifap p licable)

H ow long have you been involved w ith the ap p licantin thiscap acity?

O r g anization StreetA ddress(ifap p licable) C ity

State ZIP Daytim e P hone

Com m e nts& Im pre ssions

P lease p rovide your p ersonalcom m entsand im p r essionsreg arding the ap p licant’schar acter:

P astor/Refer ence Sig nature Date

Ark of Safety Christian Academy

8 5-1 7 9 W aianae Valley RoadW aianae, H awaii967 92

Email: ac ad emy@ aos hawaii. c omP h: (8 0 8 )696-8 92 8 Fax: (8 0 8 )696-1299 W ebs ite: www. aos hawaii. c om

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

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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