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Toledo Junior Academy

Student Registration Forms

Step 1 of 13 - Student Registration Forms

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Student Registration Forms
Student Name*
First Name Middle Name Last Name
Date of Birth (MM/DD/YYYY)*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Race*
Age as of today*
City & State of Birth*
Address
Street Address City State / Province / Region ZIP / Postal Code
Student resides with:*
- Both Parents
- Mother
- Father
Student’s Address
Same as home address

Street Address City State / Province / Region ZIP / Postal Code
Public School District
Public School your child would be assigned to
Are there legal custody issues that the school should be made aware of?
- Yes
- No
If yes, please explain
Does your child require an Individualized Educational Plan (IEP)?
- Yes
- No
If yes, please attach a copy of the IEP report.
Drop files here or
Birth Certificate is attached:
- Yes
- No
Birth Certificate
Drop files here or
Request for Records is attached:
- Yes
- No
Request for Records
Drop files here or
Consent
I verify that all the information on this form is accurate and true to the best of my knowledge.
Parent/Guardian’s Signature
Date
Date Format: MM slash DD slash YYYY

Student Registration--Parent/Guardian Information
Parent/Guardian #1 Name*
First Name Last Name
Relationship to child*
Cell Phone #*
Parent Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Occupation*
Company*
Work Phone #*
Parent/Guardian #2 Name
First Name Last Name
Relationship to child
Cell Phone #
Parent Email
Address
Street Address City State / Province / Region ZIP / Postal Code
Occupation
Company
Work Phone #
Consent
I verify that all the information on this form is accurate and true to the best of my knowledge.
Parent/Guardian’s Signature
Date
Date Format: MM slash DD slash YYYY

Name
First Last
Social Security #
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Secondary person responsible for account (If applicable)
Name
First Last
Social Security #
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Child(ren) enrolled at Toledo Junior Academy
Student Grade

Grades K-8
Year Tuition: $6166
Year Registration Fee: $300 per student

Option 1: Tuition Fees may be paid in 10 monthly installments. The first installment is to be paid at the beginning of the school year in August. The remaining installments are due by the 15th of each month. It is imperative that your account is kept current to avoid a late fee of 2.5% of the payment amount that is due.

Option 2: My child is eligible for a full EdChoice scholarship. I understand that I am still responsible for the $300 per-student registration fee, and if during the course of the school year I lose my scholarship, I am responsible for the remainder of my child(ren)’s tuition in full.

Option 3: My child is eligible to receive a partial scholarship (including EdChoice, the Northwest Ohio Scholarship), The remainder of my tuition will be paid in 10 monthly installments as in Option 1 above. I understand that I am still responsible for the $300 per-student registration fee and if during the course of the school year I lose my scholarship, I am responsible for the remainder of my child(ren)’s tuition in full.
Option Selected (Please check one)
- Option 1
- Option 2
- Option 3
I understand that as the signer of this financial sheet, my account with Toledo Junior Academy must be paid in full before requests are made for report cards, transcripts, or the issuing of diplomas. I also understand and accept the financial responsibilities when enrolling my child(ren) as a student at Toledo Junior Academy.
*There is no other financial agreement not included on the face of this contract, and if at such time as any other financial arrangements are agreed upon; such agreements will not be valid unless written and signed by all parties.
Parent/Guardian’s Signature
Date
Date Format: MM slash DD slash YYYY
Finance Committee Member
Date
Date Format: MM slash DD slash YYYY

We, the undersigned parent(s) or guardian(s) of the minor(s) listed below do hereby consent to any x-ray
examination, anesthetic, medical or surgical diagnosis or treatment instructions of
or any office of said physician or at a licensed hospital. It is understood that reasonable effort will be made to contact the doctor listed above before any other physician is called.

It is further understood that this consent is given in advance of any specific diagnosis or treatment, which might be required and is given to authorize Toledo Junior Academy or the physician to exercise their best judgment as to the requirements of such diagnosis or treatment.

This consent shall remain in continuous effect until revoked in writing and delivered to the physician named above or to the school entrusted with the custody of said minor.

We hereby authorize any hospital physician, or other person who has attended or examined the minor to furnish to the school insurance service or its representative any and all information with respect to any illness, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical reports. A copy of this authorization shall be considered as effective and valid as the original
Student’s name
The following person(s) can be contacted in case of emergency
Last Name First Name Relationship Phone Number
Name of child’s primary care physician
Phone number
In the event of emergency transportation, students will be taken to the nearest hospital as determined by the paramedics for emergency care. A staff or faculty member will accompany and remain with the student until a parent/guardian arrives.
Signature
Date
Date Format: MM slash DD slash YYYY

Student’s Name
First Last
Sex
Age
Date of Birth
Date Format: MM slash DD slash YYYY
Objective Data
Height %
Weight %
B.P.
Screening Tests
Vision: Date Done
Date Format: MM slash DD slash YYYY
Distance Acuity
- pass
- fail
- not done
Muscle Balance
- pass
- fail
- not done
Farsightedness
- pass
- fail
- not done
Color
- pass
- fail
- not done
Child wears glasses?
- Yes
- No
Tested with glasses?
- Yes
- No
Referral made?
- Yes
- No
Hearing: Date Done
Date Format: MM slash DD slash YYYY
R-ear
- pass
- fail
- not done
Audiometric Thresholds
L-ear
- pass
- fail
- not done
Audiometric Thresholds
Other tests (specify)
Child wears hearing aid?
- Yes
- No
Tested with hearing aid?
- Yes
- No
Referral Made?
- Yes
- No
Speech/Language
Speech assessment
- done
- not done
Child has:
no discernable speech problem possible problem with: articulation rhythm voice language
Laboratory Tests
Hematocrit/Hemoglobin Urine Protein Urine Blood Urine Glucose Other
Diagnostic Procedures
TB Skin Tes
Date Result
Chest X-Ray
Date Result
Other
Date Result

Date examined
Child is essentially normal
Child has abnormalities as follows
Is this child able to participate fully in the following?
- Yes
- No
Limitations:
A. Classroom and academic activities?
B. Physical education classes
C. Competitive activities
D. Contact and collision sports
If limitations are advised, please specify those
If this child has any physical, developmental, or behavior problems, how can the school assist with special programs, placement, or attention?
Physician’s Assessment
Areas of Concern Recommendation for School Management

*NOTE: PHYSICIAN’S OFFICE: Please attach immunization records.
Physician’s Name
Physician’s Signature
Address
Phone
Date Signed
Date Format: MM slash DD slash YYYY

It is recognized that some students must take medication during school hours. Parents/Guardians/Residential facility personnel are encouraged to administer medication before and after school whenever possible.
Return the completed form to the Health Services Coordinator in your child’s building.
Student’s Name
DOB
Date Format: MM slash DD slash YYYY
Telephone#
Address
School
Grade
Teacher/Team/ID#
TO BE COMPLETED BY THE STUDENT’S PHYSICIAN
Name of Medication
Dosage
Frequency and Route
Student to Carry Medication?
- Yes
- No
(Applies to Emergency Medications only--EpiPens, inhalers or other specific emergency treatment identified by physician.)
Student to Self-Administer Medication?
- Yes
- No
(“Yes” indicates the student has been instructed in proper use, expected results and side effects of medication.)
Date to Begin Administration
Date to Terminate Administration
Possible Side Effects
Physician
Physician Telephone #
Special Storage Instructions
Physician’s Signature
The medicine must be in oral, topical, rectal, inhalation or subcutaneous/intramuscular injectable form. It must be in a clearly marked container from the pharmacist. The label must show the child's name, the dosage directions, the doctor's name, and the prescription number. Identification of the potential for interaction with other medications taken by the student is the responsibility of the prescribing physician.

TO BE COMPLETED BY PARENT/GUARDIAN OR RESIDENTIAL FACILITY REPRESENTATIVE WITH CONSENT TO ACT ON BEHALF OF PARENT OR GUARDIAN
Pharmacy
Telephone #
The undersigned agree not to file or make any claim against anyone for negligence in connection with the administration or non-administration of any medicines and further agree to save such individuals and hold them harmless from any liability incurred as a result of the administration or non-administration of any medicines. I give my permission for the principal or his/her designee to administer the prescribed medication.
Signature
Date
Date Format: MM slash DD slash YYYY

Student’s Name
DOB
Telephone
Address
School
Grade
Teacher/Classroom
Please list the non-prescription medications (Tylenol, Ibuprofen, Cough Drops, Tums, etc.) for dispensing below:
Medication
I hereby give my permission to the school staff of Toledo Junior Academy to administer the over the counter medicines listed above in accordance with the directions for use on the container/box to my child if the need arises.
Please contact me if any of these medications are administered. If you are unable to reach me, I give the staff of Toledo Junior Academy permission to send a text, leave a message, or leave a note in my child’s folder explaining the situation.
Parent Signature
Date
Date Format: MM slash DD slash YYYY
Parent Signature
Date
Date Format: MM slash DD slash YYYY
* I release Toledo Junior Academy from any liability from administering the above non-prescription medications.

Toledo Junior Academy gathers images and video, through the course of a child’s schooling, to tell the story of the school’s mission and to promote quality Adventist education. The school’s board, administration, and faculty appreciate your cooperation and consent allowing school officials to photograph/video your child for various school– related activities. You have our assurance that these images/videos will be used only for official purposes, with the respect and consideration to which all parties are entitled.
I grant Toledo Junior Academy the right to take photographs/video of my child. I authorize Toledo Junior Academy, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically. I agree that Toledo Junior Academy may use such photographs/videos of my child with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.
I have read and understand the above:
Signature
Printed Name
Child’s Name
Date
Date Format: MM slash DD slash YYYY
I grant Toledo Junior Academy the right to take photographs/video of my child. I authorize Toledo Junior Academy, its assigns, and transferees to print and use these photographs/video ONLY within the Toledo Junior Academy School facility. Photographs/video of my child may NOT be used for public access use such as publicity, advertising, or Web content.
I have read and understand the above:
Signature
Printed Name
Child’s Name
Date
Date Format: MM slash DD slash YYYY

A separate form must be filled out for each child. If you need to add names to this list later, please contact the office to submit an amended list. Additional people will not be added to this list unless submitted in writing--a phone call will not suffice. If a parent is legally barred from picking up your child, we must have a copy of the restraint order or custody agreement in your child’s file for enforcement.
Student’s Name
DOB
Date Format: MM slash DD slash YYYY
Parent/Guardian Name Address Home Phone Work Phone
I give permission for the following individuals to pick up my child from Toledo Junior Academy. I understand that a driver’s license will be required as proof of identity for anyone who is not known or recognized (including myself). I also understand that my child will not be released to any individual not on this list.
Name Phone Number
Parent/Guardian’s Signature
Date
Date Format: MM slash DD slash YYYY
Parent/Guardian’s Signature
Date
Date Format: MM slash DD slash YYYY

Internet Resources:
The Internet is an electronic highway connecting computers worldwide, with millions of individual subscribers, government agencies, businesses and educational institutions, and much more. By receiving access to computers and people all over the world, there also comes the availability of material that may not have any educational value or be considered appropriate for students. Toledo Junior Academy will take every available precaution to monitor/restrict access to such material. However, now with a global network, it is impossible to control all materials.
Acceptable Use Policy:
- Students may only use the Internet under the supervision of a sponsoring educator.
- Users should never reveal personal information such as addresses or telephone numbers of themselves, students, staff members, others, or of the school.
- Students should remember all activities accomplished via the Internet will not only reflect on the user, but upon Toledo Junior Academy.
- Use of the Internet to access inappropriate material is prohibited.
- Hate mail, harassment, discriminatory remarks, and other antisocial behavior are prohibited.
- Users shall not modify passwords, files, data, software, or hardware in any way unless directed to do so by a teacher.
- Users shall not access unsafe files or install programs on the computers.
- Malicious use of the Internet to develop programs that infiltrate a computer or computer system and/or cause damage is prohibited.
- TJA reserves the right to log Internet use and to monitor user accounts.
- The school administration/teachers reserve the right to temporarily or permanently suspend access by any user who does not comply with the Acceptable Use Policies or for any reason deemed inappropriate by the system administrator to maintain the integrity of the network.
- Parents will be notified if a student violates any of these policies.
Parents: I have read the policy stated above regarding the use of the Internet on the school computers. I understand that the school provides Internet access for educational purposes. I also recognize that it is impossible for the school to restrict access to all unacceptable material. I realize the risks involved and I give my child named below permission to use the Internet.
Parent/Guardian’s Signature
Date
Date Format: MM slash DD slash YYYY
Parent/Guardian’s Signature
Date
Date Format: MM slash DD slash YYYY
Students: I understand the policy stated above regarding usage of the Internet on the school computers. I recognize that I am responsible for all my actions and any violation may result in my privileges being revoked and school disciplinary action.
Student’s Name (Printed)
Student’s Signature
Date
Date Format: MM slash DD slash YYYY

- If your child must have a cell phone that is brought to school, it must be turned into your child’s teacher (or the teacher in charge) each morning. It will remain in that teacher's possession until dismissal. Cell phones are not permitted to be out and in use at TJA.
- All students/parents are required to sign this Cell Phone Contract each year as a proof of acknowledging the TJA Cell Phone Policy.
- If you need to contact your child for any reason during the school day, please call the TJA front office or communicate through your child’s teacher’s preferred method of communication.
- At times, a student may need to contact a family member to check on ride status after school. This is an acceptable practice, but your child’s teacher must be asked prior to the text/call being made.
Cell Phone Possession Consequences:
- Students who “forget” to turn in their phones are warned the first time.
- The second time, a parent/guardian will be notified. We will collect the phone for the parent to pick up from the office at the end of the day.
- For the third offense, your child will not be allowed to bring a phone to school for the remainder of the school year.
Please read and sign below.
Name
My child needs to have a cell phone for use before/after school outside of TJA school grounds. I understand and agree to the policy above, and I authorize my child to bring a cell phone to TJA to be stored with their classroom teacher throughout the school day. I understand that TJA is not liable for lost, damaged, or stolen cell phones. My child will adhere to the policies listed above and I fully support TJA in their effort to maintain a high level of academic excellence and positive, safe environment at Toledo Junior Academy.
Signed (Parent/Guardian)
Date
Date Format: MM slash DD slash YYYY
Signed (Student)
Date
Date Format: MM slash DD slash YYYY

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