Iglesia Evangélica Menonita ACADEMIA MENONITAacademiamenonitasj.org/downloads/new_students.pdf ·...

18
-p EN ESPAÑOL AL DORSO November 2015 Dear parents of new admission students: May the Lord bless you and your family! Thank you for your interest in Academia Menonita as an option for your son’s or daughter’s education. It is an honor for us to have your trust and hopes. During 54 years Academia Menonita has pursued to empower our students with a sound educational and spiritual experience that will promote their development as citizens who contribute in forming a better world as they follow the Lord’s will. We are pleased to notify you that the applications for new admission for school year 2016-2017 will be accepted for submittal from November 11, 2015. It is very important that you follow the process, especially the dates and the documents you have to submit. To apply, you only need to submit: Application Form original Birth Certificate copy of the Social Security card copy of a bill (to verify mailing address) $15 of Processing Fee Nevertheless, the submittal of the rest of the documents must be done promptly, as no student will be evaluated for admission until the corresponding documents are complete. Therefore, it is very important that you be prompt in collecting and submitting them. The transcriptions must be complete (of all years in school) and include the first semester of the current year. The acceptance of Pre-kinder and Kindergarten applications is limited to the spaces available, and therefore we recommend you to submit your application as soon as possible. We thank you again for your interest in Academia Menonita. Sincerely, Ramonita Rivera-Torres Administrator Iglesia Evangélica Menonita ACADEMIA MENONITA 1751 ASOMANTE STREET URB. SUMMIT HILLS SAN JUAN, PUERTO RICO 00920 Church (787) 782-4365 School (787) 783-1295 Fax (787) 783-1280

Transcript of Iglesia Evangélica Menonita ACADEMIA MENONITAacademiamenonitasj.org/downloads/new_students.pdf ·...

-p

EN ESPAÑOL AL DORSO November 2015 Dear parents of new admission students: May the Lord bless you and your family! Thank you for your interest in Academia Menonita as an option for your son’s or daughter’s education. It is an honor for us to have your trust and hopes. During 54 years Academia Menonita has pursued to empower our students with a sound educational and spiritual experience that will promote their development as citizens who contribute in forming a better world as they follow the Lord’s will. We are pleased to notify you that the applications for new admission for school year 2016-2017 will be accepted for submittal from November 11, 2015. It is very important that you follow the process, especially the dates and the documents you have to submit. To apply, you only need to submit:

Application Form

original Birth Certificate

copy of the Social Security card

copy of a bill (to verify mailing address)

$15 of Processing Fee Nevertheless, the submittal of the rest of the documents must be done promptly, as no student will be evaluated for admission until the corresponding documents are complete. Therefore, it is very important that you be prompt in collecting and submitting them. The transcriptions must be complete (of all years in school) and include the first semester of the current year. The acceptance of Pre-kinder and Kindergarten applications is limited to the spaces available, and therefore we recommend you to submit your application as soon as possible. We thank you again for your interest in Academia Menonita. Sincerely, Ramonita Rivera-Torres Administrator

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1751 ASOMANTE STREET URB. SUMMIT HILLS

SAN JUAN, PUERTO RICO 00920

Church (787) 782-4365 School (787) 783-1295 Fax (787) 783-1280

IN ENGLISH ON BACK

Noviembre 2015 Estimados padres de estudiantes de nueva admisión: ¡Que Dios les bendiga a ustedes y sus familias! Gracias por su interés en la Academia Menonita como opción para ser el centro de enseñanza de su hijo o hija. Es un honor para nosotros el gozar de su confianza y esperanza. Por 54 años la Academia Menonita se ha mantenido en pos de facultar a nuestros estudiantes con una experiencia educativa y espiritual sólida, que promueva su desarrollo como ciudadanos que contribuyen a un mundo mejor, siguiendo la voluntad de Dios. Nos place notificarles que las solicitudes de nuevo ingreso para el año escolar 2016-2017 podrán ser sometidas desde el 11 de noviembre de 2015. Es muy importante que sigan el proceso, especialmente las fechas y los documentos que tienen que someter. Para solicitar, solamente necesita someter:

Solicitud de Admisión

Certificado de Nacimiento original

copia de la tarjeta de Seguro Social

copia de alguna factura (para verificar la dirección postal)

$15 de procesamiento Sin embargo, la entrega del resto de los documentos debe hacerse con prontitud, pues ningún estudiante será evaluado para admisión hasta que sus documentos estén completos. Por lo tanto, es muy importante que se apresure en recopilar y someter los mismos. Tenga en cuenta que las transcripciones de crédito deben ser completas (por todos los años de estudio) y deben incluir el primer semestre del año en curso. La aceptación de solicitudes de Prekínder y Kindergarten está limitada a los espacios disponibles, por lo que le recomendamos que entregue su solicitud a la brevedad posible. Gracias nuevamente por su interés en la Academia Menonita. Sinceramente, Ramonita Rivera Torres Administradora fan

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1751 ASOMANTE STREET URB. SUMMIT HILLS

SAN JUAN, PUERTO RICO 00920

Church (787) 782-4365 School (787) 783-1295 Fax (787) 783-1280

EN ESPAÑOL AL DORSO

2016-2017 REGISTRATION PROCESS

Dates of Registration:

New Admission Siblings of Present Students November 11, 2015 – January 29, 2016

New Students from February 1, 2016

Process for new students and re-admission: To apply for Pre-Kinder, Kinder, and 1st grade, an original Birth Certificate must be included with the Application. Students must be 4, 5, and 6 years old respectively by October 31, 2016, and master the toilet training. From second grade forward, the minimum average for admittance is 2.50.

Step 1: Submit to the Registrar: a. Admission Application b. Birth Certificate c. copy of Social Security card d. copy of any bill (AAA, AEE, etc.) to verify complete mailing address in database. e. Processing Fee ($15.00) f. available documents of Step 3, if any.

Step 2: Take Entrance Exam at Learn Aid of Puerto Rico, Inc. (call 787-764-2665 for appointment). Step 3: The following documents must be submitted in their entirety for admittance evaluation:

Step 4: Appointment for interview and/or meeting with parents and/or student. Step 5: Submittal of registration forms and payment of Registration and Initial Fees. After the student

complies with the entrance exam, required documents, and interview, it will be determined if the student is admitted or not. If admitted, the parents will be given the following forms for completion, signature, and return in the following 8 days, in order to pay the registration:

Registration payment without ALL the required documents will NOT be accepted (forms must be filled in all parts; documents must be complete in its entirety).

If you do not register your child by the date you are given, we will understand that you are not interested in our school for school year 2016-2017.

Re-admission: Approval of faculty and administration is required for re-admission.

From Second grade forward 1. Admission Application, completed and signed 2. Birth Certificate 3. Two (2) recent 2 x 2 photographs 4. Updated P-VAC-3 Immunization Certification emitted by

the Puerto Rico Department of Health (green document) 5. Complete Transcript (of all the finished grades) and the

Progress Report to the date of the registration application. 6. Conduct Letter emitted by the Director of the present

school. 7. Two (2) recommendation letters from the teachers of the

present grade. 8. Psychometric Evaluation (valid for 1 year) 9. Credit Letter of the present school.

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1751 ASOMANTE STREET SUMMIT HILLS SAN JUAN, PUERTO RICO 00920

Church (787) 782-4365 School (787) 783-1295 Fax (787) 783-1280

www.acadmensj.org / e-mail: [email protected]

1. Agreement Form of the “Handbook for Students and Parents”, with the complete signatures. 2. Emergency Card 2016-2017 (it must be filled in ALL ITS PARTS and signed). 3. Health Certificate. It must be used the document provided by the Academy. 4. Socioeconomic Study (for school’s statistic purposes when applying for services) 5. Service Selection (the Payment Agreement must be done by July 31, 2016)

Pre-Kinder 1. Admission Application, completed and signed 2. Birth Certificate 3. Two (2) recent 2 x 2 photographs 4. Updated P-VAC-3 Immunization Certification emitted by the

Puerto Rico Department of Health (green document) 5. Conduct Letter emitted by the Director of the present school or

daycare, if applicable.

Kindergarten and First Grade 1. Admission Application, completed and signed. 2. Birth Certificate 3. Two (2) recent 2 x 2 photographs 4. Updated P-VAC-3 Immunization Certification emitted by the

Puerto Rico Department of Health (green document). 5. Conduct Letter emitted by the Director of the present school. 6. Psychological Evaluation (valid for 1 year) 7. Credit Letter of the present school.

PROCESO DE MATRÍCULA 2016-2017

Fechas de Matrícula:

Hermanos de estudiantes actuales 11 de noviembre de 2015 – 29 de enero de 2016 (de nuevo ingreso)

Estudiantes Nuevos 1 de febrero de 2016 en adelante

Proceso para estudiantes nuevos y readmisiones: Para solicitar Prekínder, Kinder y 1er grado, deberá incluir con la Solicitud, un Certificado de Nacimiento original. Deberá tener cumplidos 4, 5 y 6 años, respectivamente, al 31 de octubre de 2016 y dominar el uso del baño (“toilet training”). De segundo grado en adelante el promedio mínimo de admisión es 2.50.

Paso 1: Someter a la Registradora: a. Solicitud de Admisión b. Certificado de Nacimiento c. copia de

la tarjeta de Seguro Social d. copia de alguna factura (AAA, AEE, etc.) para verificar dirección postal completa en base de datos. e.Cuota de Procesamiento ($15.00) f. documentos disponibles del Paso 3, si alguno.

Paso 2: Tomar el Examen de Admisión en Learn Aid de Puerto Rico, Inc. (787-764-2665 para cita). Paso 3: Los siguientes documentos tienen que someterse en su totalidad para la evaluación de admisión:

Paso 4: Cita para entrevista y/o reunion con padres y/o estudiante. Paso 5: Someter las formas de matrícula y pago de Matrícula y Cuota Inicial. Luego de que el estudiante

cumpla con el examen de admisión, los documentos requeridos y la entrevista, se determinará si el estudiante es admitido o no. Si es admitido, se le entregará a los padres los siguientes documentos para ser completados, firmados y devueltos en los siguientes 8 días para poder pagar la matrícula del estudiante:

NO se aceptarán pagos de matrícula sin TODOS los documentos requeridos (las formas tienen que estar llenas en todas sus partes; los documentos tienen que estar completos en su totalidad).

Si no matricula al estudiante en las fechas indicadas, entenderemos que no está interesado en nuestra escuela para el año escolar 2016-2017.

Readmisión: Se requiere aprobación de la facultad y la administración para readmisión.

Prekínder 1. Solicitud de Admisión a la Academia, completa y firmada 2. Certificado de nacimiento 3. Dos (2) fotografías 2 x 2 recientes 4. Certificado de vacunas P-VAC-3 emitido por el Departamento

de Salud de Puerto Rico (documento color verde) 5. Carta de conducta otorgada por el Director de la escuela/cuido

de procedencia, si aplica.

Kindergarten y Primer Grado 1. Solicitud de Admisión a la Academia, completa y firmada 2. Certificado de nacimiento 3. Dos (2) fotografías 2 x 2 recientes 4. Certificado de vacunas P-VAC-3 emitido por el Departamento

de Salud de Puerto Rico (documento color verde). 5. Carta de conducta otorgada por el Director de la escuela de

procedencia. 6. Evaluación Psicológica (vigencia: 1año). 7. Carta de crédito de la institución anterior.

Segundo Grado en Adelante 1. Solicitud de Admisión a la Academia, completa y firmada 2. Certificado de nacimiento 3. Dos (2) fotografías 2 x 2 recientes 4. Certificado actualizado de vacunas P-VAC-3 emitido por el

Departamento de Salud de Puerto Rico (documento color verde).

5. Transcripción de créditos completa (de todos los grados cursados) y las notas en progreso a la fecha de la solicitud de matrícula.

6. Carta de conducta otorgada por el Director de la escuela de procedencia.

7. Dos (2) cartas de recomendación de sus maestros del grado actual.

8. Evaluación Psicométrica (vigencia: 1año). 9. Carta de crédito de la institución anterior.

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1. Hoja de Compromiso del “Manual General para Estudiantes y Padres”, con firmas completas 2. “Emergency Card” 2016-2017 (debe estar lleno en TODAS SUS PARTES y firmado) 3. Certificado Médico de Salud. Debe utilizarse el formulario que provee la Academia. 4. Estudio Socioeconómico (para propósitos estadísticos de la escuela en petición de servicios) 5. Selección de Servicios (el Acuerdo de Pago debe hacerse en/antes del 31 de julio de 2016)

IN ENGLISH ON BACK

REGISTRATION AND PAYMENTS INFORMATION 2016-2017

Class Hours (all grades): 7:45am-3:00pm

I. ADMISSION APPLICATION

All new students: All applicants pay the Processing Fee of $15.00 at Academia Menonita. The entrance exam, which is administered at Learn Aid of Puerto Rico, Inc. (787-764-2665), is paid to them, at a cost established by them.

II. REGISTRATION

Present students: The parents of present students must submit the Admission Application form with the documents and

the required photographs, as well as the Registration Fee of $375.00, in order to register. This year we have established a payment system in 3 installments for the registration fee, of $125.00 each. The due dates for each installment are the following: November 20, 2015, December 16, 2015, and January 29, 2016. January 29, 2016 is the due date for the Registration Fee, be it in installments or in its entirety. After said date, space availability will not be

guaranteed and the registration payment will have a late charge of $50.00. Registration Fee is non-refundable. Approval of faculty and administration is required for re-admission. Academia Menonita reserves the right to admittance.

New students: Parents must comply with the requirements for admission. At the moment of registration, parents must

pay the Registration Fee of $400.00 (per student), and the Initial Fee of $325.00 (per family). Registration Fee and Initial Fee are non-refundable. Approval of faculty and administration is required for admission. Academia Menonita reserves the right to admittance.

III. PHYSICAL FACILITIES FEE: All families will pay a monthly Physical Facilities Fee of $35.00

($350.00 annually) or $300.00 if it is paid by June 30, 2016. This payment will be refundable according to the

regulations established in the “Handbook for Students and Parents”.

IV. TUITION AND OTHER FEES The Tuition Fee is divided in ten (10) payments. The first one is due on August 1, 2016. All succeeding payments are due on the first day of each month. The annual fees described below are due on the first payment.

GRADE TUITION HARD- LEARN CLASS- INSU- ID EMERGENCY LABOR- RETREAT LOCKER COVER BK AID TEST ROOM RANCE CARD MGMT PLAN ATORY FEE (monthly) FEE (yr)* (yearly)** FEE (yr) (yearly) FEE (yr) FEE (yearly) FEE (yr) (yearly) (yr)*** .

PK-K $331.00 - - - $40.00 (K) $75.00 $10.00 $5.00 $5.00 - - - - - - - - - 1-3 346.00 $150.00 40.00 75.00 10.00 5.00 5.00 - - - - - - - - - 4-6 363.00 150.00 40.00 75.00 10.00 5.00 5.00 - - - $40.00 (6th) - - - 7-8 377.00 175.00 40.00 75.00 10.00 5.00 5.00 $20.00 40.00 $20.00 9-12 423.00 200.00 40.00 75.00 10.00 5.00 5.00 20.00 40.00 20.00 . *If any rented book is lost, parents must pay the cost of its replacement. **Except PK and 12th grade, which do not take the Learn Aid Test.

***An official lock provided by the school is to be used with lockers. The cost of the lock is $15.00. If official lock is lost, the parents will pay said amount for its replacement.

Scholarship Fund: $10.00 annually per family.

PTO Fee (Parent-Teacher Organization): $10.00 annually per family.

Graduation Fee: $150.00 per student (grades Kinder, 8th, and 12th). This fee does not include the amount of

$25.00 of the cost of the gown, which must be purchased when stated, at the Business Office.

Preschool Care (optional): A supervised preschool care will be offered after school, from 3:00 to 5:00 p.m., for

Preschool (Pre-Kinder and Kinder) students. THIS IS NOT A TUTORING SERVICE. The monthly payment will be $80.00 per student and includes one (1) snack daily during said period. This service is not fractioned by day. Spaces are limited and depend upon availability at the moment of registration. The last day to apply for this service is July 29, 2016.

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1751 ASOMANTE STREET - SUMMIT HILLS SAN JUAN, PUERTO RICO 00920

School (787) 783-1295 – Fax (787) 783-1280 www.acadmensj.org / email: [email protected]

Study Hall (optional): A supervised study hall will be offered after school, from 3:15 to 5:15 p.m., to students from

grades 1st through 12th. THIS IS NOT A TUTORING SERVICE. The monthly payment will be $75.00 per student. Spaces are limited and depend upon availability at the moment of registration. The last day to apply for this service is July 29, 2016.

Only one change in the registration of Study Hall services will be allowed per school year, per family.

Tutoring (Study Hall Plus) (optional): A tutoring service will be offered after school, for the needs in specific subjects, for students from 1st to 12th grade. The tutoring will be from Monday to Thursday, and on Friday they attend the

Study Hall. The monthly payment will be $200.00 per student.

Therapies (new optional service): Occupational Therapy, Speech/Language Therapy, and Educational Therapy will be offered after school, from 3:00 to 5:00 p.m. by external therapists, but inside the school premises. This facilitates the access to these services for our students without the need of the parents having to mobilize them to other places. The additional information and costs will be available soon.

V. LUNCH PROGRAM AND SNACKS (Prices do not include “IVU”)

Preschool (Pre-Kinder and Kinder): As part of the Preschool level program, all students are to participate in the Monthly Lunch and Snack Plan, which will include 2 snacks (1 in the morning and 1 in the afternoon) and lunch. This payment, which is specified below, is added to the monthly payment. Lunch and snack tickets are not permitted.

Grades 1st – 12th (optional): Students must either buy lunch from the cafeteria or bring lunch from home. There are two options in buying lunch from the cafeteria: one is buying lunch tickets in “La Tiendita”, the other one is the Monthly Lunch Plan that consists in including this payment to the monthly payment. The school recommends the monthly lunch plan for those who will have lunch from the cafeteria every day. This way you will not risk losing individual tickets and you will save time. Only one change in the lunch plan will be allowed per school year and it must be done during the first semester. Grade Monthly Lunch Plan Individual Tickets

PK-K $103.30 (includes 2 snacks) - - - 1 – 3 65.90 $38.88 (10 tickets) 4 – 6 78.40 46.08 (10 “ ) 7 – 12 88.92 26.14 ( 5 “ )

The School Cafeteria offers breakfast from 7:00 to 7:30 a.m. and snacks at the corresponding recess periods. Snack

tickets are sold in strips of 10 for $8.85, at “La Tiendita”. Snack tickets are not sold individually or on credit. No cash is used at the cafeteria; only tickets can be used to buy food.

“La Tiendita” will be open from 7:00 to 7:45 a.m. and, for students, also from 9:30 to 10:00 a.m.

These prices are subject to change without notice.

VI. PAYMENT POLICY: At the moment of registration, all families must sign a payment agreement at the

Business Office. A 6% discount of the total tuition fee will be granted to those families who make the payment of all the

fees for the entire year by August 15, 2016.

Any month attended at least one day will be considered a full month.

Late payments and returned checks: There will be an additional charge of $25.00 for each returned check

and $25.00 for delayed payment (after day 15 of each month).

VII. TRANSCRIPTS: A $15.00 fee will be charged for each student transcript requested. Please allow three

or more working days for the transcript to be completed. In order to process any transcript, official document, record, report card, etc., said family’s account must not have any payment pending to the school; as soon as the remaining balance is paid, the solicited document will be processed.

VIII. TRANSPORTATION: Parents are responsible for making their own transportation arrangements.

ACADEMIA MENONITA RESERVES THE RIGHT OF ADMISSION AND RE-ADMISSION.

INFORMACIÓN MATRÍCULA Y COSTOS 2016-2017

I. SOLICITUD DE ADMISIÓN Horario de clases (todos los grados): 7:45 AM-3:00 PM

Todo estudiante nuevo: Todo el que solicite admisión pagará la Cuota de Procesamiento de $15.00 en la Academia Menonita. El examen de ingreso, el cual es tomado en Learn Aid de Puerto Rico, Inc. (787-764-2665) es pagado a ellos, al costo que ellos establecen.

II. MATRÍCULA

Estudiantes actuales: Los padres de los estudiantes actuales deben someter la Solicitud de Admisión con los documentos

y fotografías requeridas, así como el pago de la Cuota de Matrícula de $375.00 para poder matricular. Se ofrece un sistema de pagos en 3 plazos para la cuota de matrícula, de $125.00 cada uno. Las fechas límites para cada plazo son las siguientes: 20 de noviembre de 2015, 16 de diciembre de 2015 y 29 de enero de 2016. El 29 de enero de 2016 es la fecha límite para el pago de matrícula, sea a plazos o en su totalidad. Luego de esta fecha los espacios no serán garantizados y el

pago de matrícula tendrá un recargo de $50.00. La Cuota de Matrícula no es reembolsable. Se requiere aprobación de la facultad y la administración para readmisión. La Academia Menonita se reserva el derecho de admisión.

Estudiantes nuevos: Deben cumplir con los requisitos de admisión. Al momento de la matrícula, los padres deben pagar

la Cuota de Matrícula de $400.00 (por estudiante) y la Cuota Inicial de $325.00 (por familia). La Cuota de Matrícula y la Cuota Inicial no son reembolsables. Se requiere aprobación de la facultad y la administración para admisión. La Academia Menonita se reserva el derecho de admisión.

III. CUOTA DE FACILIDADES FÍSICAS: Todas las familias pagan una cuota mensual de facilidades físicas

de $35.00 ($350.00 anuales) o podrán acogerse al descuento de $50.00 y pagar $300.00 si ésta se paga en o antes del 30 de junio de 2016. Este pago será reembolsable de acuerdo con los reglamentos establecidos en el Reglamento General para Estudiantes y Padres.

IV. CUOTA DE INSTRUCCIÓN Y OTRAS La Cuota de Instrucción está dividida en diez (10) pagos. El primer pago vence el 1 de agosto de 2016. Todos los pagos subsiguientes vencen el día primero de cada mes. Las cuotas anuales descritas a continuación deben ser pagadas en su totalidad en el primer pago.

GRADO INSTRUC. LIBROS LEARN CUOTA SEGURO TARJ. PLAN CUOTA RETIRO LOCKER ENCUAD. AID SALÓN ESCOL. ID MANEJO LAB. (mes) DURA (año)* (año)** (año) (año) (año) EMER (año) (año) (año) (año)*** . PK-K $331.00 - - - $40.00 (K) $75.00 $10.00 $5.00 $5.00 - - - - - - - - - 1-3 346.00 $150.00 40.00 75.00 10.00 5.00 5.00 - - - - - - - - - 4-6 363.00 150.00 40.00 75.00 10.00 5.00 5.00 - - - $40.00 (6to) - - - 7-8 377.00 175.00 40.00 75.00 10.00 5.00 5.00 $20.00 40.00 $20.00 9-12 423.00 200.00 40.00 75.00 10.00 5.00 5.00 20.00 40.00 20.00 . *Si algún libro alquilado es extraviado, los padres deberán pagar el costo de su reemplazo. Este renglón está sujeto a cambios, dependiendo de la cantidad de libros de encuadernación dura a utilizarse. **Excepto PK y 12mo grado, quienes no toman la prueba Learn Aid.

***Un candado oficial es provisto por la escuela para ser utilizado en los “lockers”. El costo del candado es de $15.00. Si el candado oficial de la escuela es extraviado, los padres pagarán dicho costo por su reemplazo.

Fondo de Becas: $10.00 anualmente por familia.

Cuota PTO (Organización Padres y Maestros): $10.00 anualmente por familia.

Cuota de Graduación: $150.00 por estudiante (Kinder, 8vo y 12mo grado). Esta cuota no incluye el costo de la

toga ($25.00). Esta deberá ser adquirida en la Oficina de Contabilidad cuando se indique.

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1751 ASOMANTE STREET - SUMMIT HILLS SAN JUAN, PUERTO RICO 00920

School (787) 783-1295 – Fax (787) 783-1280 www.acadmensj.org / email: [email protected]

Cuido Preescolar (opcional): Se ofrece un programa de cuido preescolar después de clases, de 3:00-5:00 P.M, para los estudiantes del Nivel Preescolar (entiéndase Prekínder y Kinder). ESTO NO ES UN SERVICIO DE TUTORÍA. El pago mensual

será de $80.00 por estudiante e incluye 1 merienda diaria durante ese horario. Este servicio no se fracciona por día.

Los espacios son limitados y están sujetos a disponibilidad al momento de hacer la matrícula. El último día para solicitar este servicio es el 29 de julio de 2016.

Estudios Supervisados (Study Hall) (opcional): Se ofrece un programa de estudios supervisados después de clases,

de 3:15-5:15 P.M., para estudiantes del 1er al 12mo grado. El pago mensual es de $75.00 por estudiante. Los espacios son limitados y están sujetos a disponibilidad al momento de hacer la matrícula. El último día para solicitar este servicio es el 29 de julio de 2016.

Solamente se permite un cambio en la matrícula de los servicios de Estudios Supervisados en el año escolar, por familia.

Tutorías (Study Hall Plus) (opcional): Se ofrece un programa de tutorías después de clases, para las necesidades en materias específicas, para estudiantes de 1ro a 12mo grado. Las tutorías son de lunes a jueves y el viernes asisten a los

estudios supervisados. El pago mensual es de $200.00 por estudiante.

Terapias: Se ofrecerán servicios de Terapia Ocupacional, Terapia del Habla/Lenguaje y Terapia Educativa. Estos servicios serán ofrecidos de 3:00-5:00 PM por terapistas externos, pero dentro del plantel escolar, facilitándoles así a los estudiantes del acceso a estos servicios sin que los padres tengan que movilizarlos a otros lugares. La información adicional y de costos estará disponible prontamente.

V. PROGRAMA DE ALMUERZOS Y MERIENDAS (Precios no incluyen “IVU”)

Preescolar (Prekínder y Kinder): Como parte del programa del Nivel Preescolar, todos los estudiantes participarán del Plan Mensual de Almuerzos y Meriendas, que incluye 2 meriendas (1 en la mañana y 1 en la tarde) y el almuerzo. Este pago, que se especifica a continuación, se añade al pago mensual. No se permite el uso de “tickets” de almuerzo ni de merienda.

1ero – 12mo grado (opcional): Los estudiantes deben comprar almuerzo de la cafetería o traer almuerzo de sus casas. Hay dos opciones para comprar almuerzo de la cafetería: una es comprando “tickets” en “La Tiendita”, el otro es a través del Plan Mensual de Almuerzos que consiste en incluir este pago en la mensualidad. La escuela recomienda el plan mensual para aquéllos que almorzarán de la cafetería todos los días. De este modo no se arriesga a extraviar “tickets” individuales y economizan tiempo. Solamente se permite un cambio de opción para comprar almuerzo en el año escolar y el mismo tiene que hacerse durante el primer semestre.

Grado Plan Mensual de Almuerzos “Tickets” Individuales PK-K $103.30 (incluye 2 meriendas) - - -

1 – 3 65.90 $38.88 (10 tickets) 4 – 6 78.40 46.08 (10 “ ) 7 – 12 88.92 26.14 ( 5 “ )

La Cafetería de la Academia ofrece desayuno desde las 7:00 hasta las 7:30 A.M. y merienda en los períodos de receso

correspondientes. Los “tickets” de merienda son vendidos en grupos de 10 por $8.85, en “La Tiendita”; no se venderán individualmente ni a crédito. En la cafetería no se utiliza dinero para adquirir alimentos. “La Tiendita” estará abierta desde las 7:00 hasta las 7:45 A.M. y, para estudiantes, también de 9:30 a 10:00 A.M.

Estos precios están sujetos a cambio sin previa notificación.

VI. POLÍTICA DE PAGOS: Al momento de matrícula, todas las familias deberán firmar un Acuerdo de Plan de

Pagos en la Oficina de Contabilidad. Se le otorga un descuento de 6% del costo total de instrucción a aquellas familias que

hacen el pago de todos los cargos para el año en su totalidad, al 15 de agosto de 2016.

Se considera un mes completo si el estudiante ha asistido a la escuela por lo menos un día.

Pagos tardíos y cheques devueltos: Hay un cargo adicional de $25.00 por cada cheque devuelto y $25.00 por pagos tardíos (luego del día 15 de cada mes).

VII. TRANSCRIPCIONES: Cada transcripción de créditos solicitada tiene un costo de $15.00. Toma tres o

más días laborables para su preparación. Para poder procesar cualquier transcripción, documento oficial, expediente, tarjeta de notas, etc., la cuenta de la familia no debe tener balance pendiente de pago; tan pronto el balance es pagado, se procesará el documento solicitado.

VIII. TRANSPORTACIÓN: Los padres son responsables por hacer sus propios arreglos de transportación.

LA ACADEMIA MENONITA SE RESERVA EL DERECHO DE ADMISIÓN Y READMISIÓN.

SSTTUUDDEENNTT AADDMMIISSSSIIOONN AAPPPPLLIICCAATTIIOONN (Please print clearly)

Date of application:_____________________ School Year applied for:____________________ Grade applied for:__________

Name:___________________________________________________________________________________________________________ (First Surname) (Second Surname) (First Name) (Middle Name)

Place of Birth:___________________________________ Date of Birth:________________________ Age:_________ Gender: F ( ) M ( ) Language(s) used at home:____________________________________________Student’s primary language:_________________________

Residential Address:________________________________________________________________________Zip Code_________________ Mailing Address:___________________________________________________________________________Zip Code_________________

Person in charge of account:_________________________________________________________Relationship:_______________________ Mailing Address of said person:_______________________________________________________________Zip Code_________________ Father or Guardian:______________________________________________________If guardian, relationship:_______________________

Home Telephone:___________________ Cellular phone:_____________________ E-mail:__________________________________ Birthplace:__________________________________ Language Spoken:______________________________

Education:___________________________________ Occupation:___________________________________ Employer:___________________________________ Position:______________________________________ Address:____________________________________ Office Telephone:______________________________

Mother or Guardian:______________________________________________________If guardian, relationship:_______________________

Home Telephone:___________________ Cellular phone:_____________________ E-mail:__________________________________

Birthplace:__________________________________ Language Spoken:______________________________ Education:___________________________________ Occupation:___________________________________ Employer:___________________________________ Position:______________________________________

Address:____________________________________ Office Telephone:______________________________

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1751 ASOMANTE STREET - SUMMIT HILLS SAN JUAN, PUERTO RICO 00920

School (787) 783-1295 – Fax (787) 783-1280 www.acadmensj.org / email: [email protected]

DO NOT WRITE IN THIS BOX

--For official use of Academia Menonita--

-FOR USE OF ADMINISTRATIVE OFFICE-

___Home ___Day Care ___PP/PK ______Left-handed ______R-handed ______Eyeglasses ______Official Complete Transcripts ______Conduct Letter ______Credit Letter ______Teacher Recommendation Letters (2) ______Psychometric Evaluation ______Original P-VAC-3 ______Copy Birth Certificate

______Health Certificate Form

______Socioeconomic Study

-FOR USE OF BUSINESS OFFICE-

_______Processing Fee-Date________

_______Entrance Exam-Date________

_______Registrat. Fee -Date________

_______Receipt Handbook

_______Emergency Card

_______Recent photographs (2) _______Initial Fee -Date________ _______Phys.Facil. Fee-Date________ _______Payment Agreement________

-FOR USE OF DIRECTOR-

Accepted

Not accepted

By:_________________

Date:_______________

______New family

______Previous family

______Present family _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

New student is sibling of present student ______

Place picture

here

Marital Status of Parents: Married ( ) Separated ( ) Divorced ( ) Widow(er) ( )

Student lives with: Both parents ( ) Mother ( ) Father ( ) Grandparents ( ) Other ( ): _________________________ If student lives with stepparents, grandparents, or other, please state:

Name(s):__________________________________________________________ Relation:____________________________________ Religious Denomination(s): Protestant ( ) Which?_______________ Catholic ( ) Jewish ( ) None ( ) Other ( ) Which?______________ Name of Church or Synagogue:______________________________________________Address:___________________________________

Attendance: Regularly ( ) Sometimes ( ) Never ( ) Children in family (please include applicant, too):

Name Age Present Grade Present School

________________________________ ______ ___________ _________________________________

________________________________ ______ ___________ _________________________________

________________________________ ______ ___________ _________________________________

NEW STUDENTS ONLY (questions 1-4)

1. List all other schools your child has attended (complete postal address).

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

2. Why have you chosen Academia Menonita for your child’s education?_____________________________________________________

3. How did you know about Academia Menonita? (if by newspaper, which?)__________________________________________________

4. Has your child been asked to leave any previous school due to discipline or failing grades? Yes ( ) No ( )

5. Has your child ever repeated a school year? Yes ( ) (grade:______) No ( )

PLEASE READ THE FOLLOWING INFORMATION. THIS APPLICATION IS NOT VALID UNLESS COMPLETED, ACCEPTED (INITIALIZED) AND SIGNED.

NOTE: Incorrect or deleted information may invalidate this application form, any previous acceptance notice, or registration in Academia Menonita. (Información incorrecta u omitida puede invalidar esta solicitud, cualquier nota de aceptación o la matrícula en la Academia Menonita.)

___ I understand that Academia Menonita works in cooperation with the neighbors surrounding the school. I agree not to park my car blocking the driveway of any neighbor or the personnel parking lot (this includes a reasonable distance from the driveway that allows the car to turn comfortably when entering or exiting said parking), nor will I blow my car horn unnecessarily, or litter

the surroundings. I also agree to follow the traffic pattern established by Academia Menonita in order to alleviate traffic congestion in the morning and in the afternoon. I understand that I COULD LOSE THE RIGHT FOR MY CHILD TO ATTEND ACADEMIA MENONITA IF I DO NOT COOPERATE WITH THE NEIGHBORS in these requests.

(Entiendo que la Academia Menonita trabaja en cooperación con los vecinos circundantes a la escuela. Acepto no estacionar mi automóvil obstruyendo la entrada de los vecinos o del estacionamiento de personal (esto incluye una distancia razonable de dicha entrada que permita que el carro pueda doblar cómodamente para entrar o salir de dicho estacionamiento), ni sonar la bocina innecesariamente, ni arrojar basura en los alrededores. Entiendo que PODRIA PERDER EL DERECHO QUE TIENE MI HIJO DE ASISTIR A LA ACADEMIA MENONITA SI NO COOPERO CON LOS VECINOS en estos requerimientos.)

___ I understand and agree TO PICK UP MY CHILD ON TIME, AS ESTABLISHED BY ACADEMIA MENONITA, AND THAT I COULD LOSE THE RIGHT FOR MY CHILD TO ATTEND THIS SCHOOL IF I DO NOT COMPLY WITH THIS AGREEMENT.

(Entiendo y acepto recoger mi hijo a tiempo, según lo establecido por la Academia Menonita, y que PODRIA PERDER EL DERECHO QUE TIENE MI HIJO DE ASISTIR A ESTA ESCUELA SI NO CUMPLO CON ESTE ACUERDO.

___ I understand and authorize Academia Menonita to use photographs or images of my son/daughter to be published in the Academy’s different means of communication and its websites, preserving respect and good withstanding towards them.

(Entiendo y autorizo a la Academia Menonita la utilización de fotografías o imágenes de mi hijo(a) para ser publicado en los diferentes medios de comunicación de la Academia y sus páginas Web, preservando el respeto y buen nombre de ellos.)

___ I understand and agree that Academia Menonita reserves the right to admission and re-admission of students. (Entiendo y acepto que la Academia Menonita se reserva el derecho de admisión y readmisión de estudiantes.)

____________________________ __________________________________________ Date Parent/Guardian’s Signature

Iglesia Evangélica Menonita

ACADEMIA MENONITA

1751 ASOMANTE STREET

SUMMIT HILLS SAN JUAN, PUERTO RICO 00920

Church (787) 782-4365 - School (787) 783-1295 - Fax (787) 783-1280

GRADO Y GRUPO ACTUAL:_____________

AÑO ESCOLAR:_____________

ESTUDIO SOCIOECONÓMICO PARA LAS ESCUELAS PRIVADAS

El propósito de esta encuesta es la de recoger la información socioeconómica de nuestros

estudiantes. Esta información nos permite contar con información solicitada por agencias de

acreditación y licencias con el propósito de solicitar las mismas. La información que

solicitamos es confidencial y no será enviada a ninguna agencia gubernamental excepto de

manera general y estadística. Gracias por su cooperación.

1. Indique el NÚMERO TOTAL de los miembros de su familia. ______________

2. Indique con quién vive el menor: ___Madre ___Padre ___Ambos Otro:__________________

3. Indique las edades, los grados, el pueblo de nacimiento y la escuela de procedencia de los

menores. Nombre de los Estudiantes Edad Grado Pueblo de

Nacimiento

(X)Escuela de Procedencia

Pública Privada

4. Seleccione con una X en el encasillado correspondiente al INGRESO FAMILIAR ANUAL.

X ANUAL X ANUAL

$15,730.00 o menos $41,748.00 a $48,415.00

$15,731.00 a $19,790.00 $48,416.00 a $55,482.00

$19,791.00 a $27,214.00 $55,483.00 a $62,549.00

$27,215.00 a $34,281.00 $62,550.00 a $69,616.00

$34,284.00 a $41,348.00 $69,617.00 o más

5. Información Básica de los padres:(favor de escribir el grado más alto obtenido en escolaridad y

en ocupación especifique el tipo de ocupación que tiene: ej: ventas, chef, maestro, ect.)

Escolaridad Ocupación

Padre:

Escolaridad Ocupación

Madre:

6. Idioma Principal Familiar________________________________

7. Pueblo de Residencia Actual______________________________

Especifique con quién.

ACADEMIA MENONITA Summit Hills

San Juan, Puerto Rico

HOJA DE COMPROMISO

Certifico haber leído completamente y comprendido este Reglamento. Además certifico haber discutido el mismo con mi hijo. Certifico también haber recibido orientación escrita sobre:

1. Protocolo para la Administración de Medicamentos 2. Protocolo para Estudiantes que Padecen de Asma 3. Protocolo contra el Hostigamiento e Intimidación 4. Política y Protocolo sobre Manejo de Casos Conforme a la Ley 246

Estamos de acuerdo con todas sus disposiciones. Como padres y/o encargados legales nos comprometemos a cumplir con este Reglamento y velaremos por que nuestro hijo cumpla cabalmente con el mismo, razón por la cual firmamos libre, espontánea y voluntariamente y con pleno conocimiento de lo que estamos haciendo.

_____________________________ _______________________________ Grado y grupo del estudiante Fecha _____________________________ _______________________________ Firma del estudiante Nombre del estudiante (letra de molde) _____________________________ _______________________________ Firma de la madre Nombre de la madre (letra de molde) _____________________________ _______________________________ Firma del padre Nombre del padre (letra de molde) ____________________________ _______________________________ Firma del encargado legal Nombre del encargado legal (letra de molde)

___________________________ _______________________________ Firma de la encargada legal Nombre de la encargada legal (letra de molde)

Si otra persona que no sea el padre o madre del menor posee la custodia legal de éste, debe firmar en los espacios correspondientes a encargado(a) legal. Si los padres del menor están divorciados: Es de suma importancia que ambos padres divorciados, y sus respectivos cónyuges (de haberlos), se comprometan seriamente con la educación y bienestar del estudiante. Por lo tanto, si ambos padres divorciados residen en Puerto Rico, deben firmar en los espacios correspondientes. Si el padre o madre han contraído nupcias nuevamente, su esposo(a) debe firmar en el lugar correspondiente. _____________________________ _______________________________ Esposa del padre (madrastra) Esposo de la madre (padrastro)

_____________________________ _______________________________ Nombre en letra de molde Nombre en letra de molde

ACADEMIA MENONITA Summit Hills

San Juan, Puerto Rico 00920

AGREEMENT FORM

I hereby certify that I have read completely and understand this Policy Handbook. Also, I certify that I have discussed the same with my child. Also, I hereby certify that I have received written information regarding:

1. Protocol for Medicine Administration 2. Protocol for Students that Suffer from Asthma 3. Protocol Against Bullying and Intimidation 4. Policy and Protocol Regarding Managing Cases in Conformity with Law 246.

We are in agreement with all of its dispositions. As parents and/or legal guardians, we are committed to comply with this Handbook and we will see to it that our child complies completely with same, therefore, signing freely, spontaneously, and voluntarily with ample knowledge of what we are doing. __________________________ ___________________________________ Student’s Grade Date __________________________ ___________________________________ Student’s Signature Student’s Name [Print] __________________________ ___________________________________ Mother’s Signature Mother’s Name [Print] __________________________ ___________________________________ Father’s Signature Father’s Name [Print] __________________________ ___________________________________ Legal Guardian’s Signature Name of Legal Guardian [Print] __________________________ ___________________________________ Legal Guardian’s Signature Name of Legal Guardian [Print]

If someone other than the minor’s parents has legal custody of same, they should sign in the corresponding spaces of legal guardian[s]. If the minor’s parents are divorced: It is very important that both divorced parents, and their respective spouses (if any), seriously commits him/herself with the education and well-being of the student. Therefore, if both divorced parents reside in Puerto Rico, they should sign in the corresponding spaces. If the father or mother has remarried, the spouse must sign in the corresponding space (below). ______________________________ ___________________________________ Signature of Spouse of remarried father Signature of Spouse of remarried mother ________________________________ ___________________________________ Print name Print name

Medical ExaminationStudent's name:__________________________________________________________________________________ First Surname Second Surname Name

Date of Birth:_____________________ Gender:_______ Blood type:________ month/day/year M or F

Student's medical historyNo Yes No Yes No Yes No Yes

Tumors Eye/Sight illness Asthma Meningitis

Hernia Deafness Short of breath Kidney illness

Diphtheria Ear-nose-throat illness Severe headaches Diabetes

Rheumatic Fever Sinusitis Dizziness/Imbalance Hypoglycemia

Heart illness Allergies Seizures Hemophilia

Stomach illness Frequent colds Epilepsy Encopresis

Genitourinary illness Thyroids Enuresis

Specify any other illnesses or conditions, present or past (if allergic, to what?), actual medical treatments/medications:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Surgical history (type and date):_________________________________________________________________________

___________________________________________________________________________________________________

Physical Examination

Height (no shoes):_______ in. Weight (no shoes):_______ lbs. Blood pressure:______/______ Pulse:_______

Sight: see enclosed form

Illness evidences:No Yes Observations

Head/Neck ___________________________________________________________________________

Mouth ___________________________________________________________________________

Ear-nose-throat ___________________________________________________________________________

Speech Difficulty ___________________________________________________________________________

Chest and Lungs ___________________________________________________________________________

Heart ___________________________________________________________________________

Chest and Lungs ___________________________________________________________________________

Hernia ___________________________________________________________________________

Skin ___________________________________________________________________________

Scars (specify) ___________________________________________________________________________

Prothesis ___________________________________________________________________________

Is the student apt to perform the normal physical activity of a Physical Education class?

Is the student apt to perform the rigorous exersice and training required in sport teams?

Observations:

Doctor's signature Doctor's name

License number Address

Examination date

Iglesia Evangélica Menonita

ACADEMIA MENONITA 1751 ASOMANTE STREET

URB. SUMMIT HILLS SAN JUAN, PUERTO RICO 00920

School (787) 783-1295 Fax (787) 783-1280

Student's Name:___________________________________________ Grade:_____________

EYESIGHT TEST

Visual accuracy: Without Rx Rx Right eye 20/ ______ 20/______ Left eye 20/ ______ 20/______ Both eyes 20/ ______ 20/______ Color vision: _____Normal _____Deficient Visual field: _____Normal _____Restricted The evaluated student _____requires or _____does not require the use of glasses or contact lenses. Observations: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ __________________________________ __________________________________ Name of Professional Evaluator Signature of Professional Evaluator License number: ____________________ __________________________________ Date of Evaluation **Please include official office seal or presentation card** DOCTOR OR OFFICE OFFICIAL SEAL

IGLESIA EVANGÉLICA MENONITA

ACADEMIA MENONITA 1751 ASOMANTE ST. SUMMIT HILLS

SAN JUAN, PR 00920

INFORMACIÓN SOBRE SELECCIÓN PARA ACUERDO DE PAGOS

Para facilitar la preparación de su Acuerdo de Pagos, favor llenar este formulario con su

selección de servicios y entregarlo junto con los documentos de matrícula.

Persona a cargo de la cuenta

Nombre con 2 apellidos _________________________________________________________

Nombre de los estudiantes

(De mayor a menor por grados) Grado

1. ___________________________________ _______

Study Hall _______ Plan de Almuerzo _______

2. ___________________________________ _______

Study Hall _______ Plan de Almuerzo _______

3. ___________________________________ _______

Study Hall _______ Plan de Almuerzo _______

4. ___________________________________ _______

Study Hall ________ Plan de Almuerzo _______

¿Pagó o pagará Cuota de Facilidades Físicas en o antes del 30 de junio correspondiente?

Si ________ No ________

Hará sus pagos a través de Telepago o ENET? Si ________ No ________

Desea libreta de pagos? Si ________ No ________

NOTA: Otros servicios como Tutorías, clases de guitarra, etc. no son incluídos en esta hoja.

ACADEMIA MENONITA ___________ 20 -20

EMERGENCY INFORMATION Grade & Group Please use black or blue ink to fill out this form. Any changes made during the year should be reported to the school. ______________________________________________,____________________________________ _____/______/______ Pupil’s (2) Last Names First Name Middle Name DOB (month/day/year) __________________________________________________________________________________ __________________ Home Address Zip Code Home Phone # ___________________________________________________________ ___________________________________________________________ Print Father’s Name –not signature-- (por favor, letra de molde legible) Print Mother’s Name –not signature-- (por favor, letra de molde legible) _________________________ _________________________ _________________________ _________________________ Work Phone # Mobile Phone # (Cellphone) Work Phone # Mobile Phone # (Cellphone) ___________________________________________________________ ___________________________________________________________ E-Mail E-Mail The parents are: married _______ divorced______ separated____ other_______ specify:___________________ Paternal authority (“patria potestad’”) belongs to: both parents_______ mother_______ father_______ other_______ specify:___________________ Legal custody (“custodia legal”)`belongs to: : both parents_______ mother_______ father_______ other_______ specify:___________________ Name and grade of any sibling, cousin, etc. who studies at Academia Menonita_______________________________________________________________ ______________________________________________________________________________________________________________________________ Blood Type ________ Does your child have any history of illness that we should know about? Please specify______________________________________ ______________________________________________________________________________________________________________________________ Is your child at present under medical treatment(s)?_______ For what reason(s)?_____________________________________________________________ Medicine(s) taken for such treatment and dosis________________________________________________________________________________________ Does your child have any allergies? Please specify. Include allergies to medications___________________________________________________________ Does your child have any physical handicap? Please specify._____________________________________________________________________________ Any other special health information that we should be aware of___________________________________________________________________________

My child may receive (please check ): Acetaminophen (Tylenol/Panadol)______ Tums______ Pepto-Bismol______

Other:___________________________during school hours when necessary from the school. (We DO NOT provide Aspirin.)

Student’s doctor and phone number_________________________________________________________________________________________________ In case of emergency and you cannot be reached by phone, what do you wish the school to do, and what hospital preference would you have? ______________________________________________________________________________________________________________________________ Name of the adults who are NOT authorized to pick up the student. (Please provide photograph with name written on back) (To unauthorize a parent, there must be an official court order stating it.) ____________________________________________ _______________ __________________________________________________________ Name Relation Phone, Cellphone, E-Mail ____________________________________________ _______________ __________________________________________________________ Name Relation Phone, Cellphone, E-Mail ____________________________________________ _______________ __________________________________________________________ Name Relation Phone, Cellphone, E-Mail ____________________________________________ _______________ __________________________________________________________ Name Relation Phone, Cellphone, E-Mail

Name of adults authorized to pick up the student. (Please provide photograph with name written on back) Mark with an “X” in the space provided those to be called in case of emergency, if parents cannot be reached. Call in case of emergency _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail

_______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail _______________________________________ _______________ ___________________________________________________ _____ Name Relation Phone, Cellphone, E-Mail

____________________________________________________ ____________________________________________________ Signature of Father (or guardian) Signature of Mother (or guardian)