Chowchilla Adventist School

CAS Application Form

Step 1 of 2

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CAS Application Package

Please note: before you start filling out the form, please make sure you have the following forms completed and saved on your computer so that the completed form can be uploaded through the file upload option on the Package.

1. Student Medical Recod
2. Consent to Treatment Form

Also, please upload the following:

1. Child's Birth Certificate
2. Immunization Record

Student Information
Child's Legal Name*
Child's First Name Middle Child's Last Name
Gender*
- Male
- Female
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Email*
Date of Birth (mm/dd/yyyy)*
Place of Birth*
Grade applying for*
Last school attended*
Does the student attend church?*
- Yes
- No
If yes, where?*
Lives with*
- both parents
- mother
- father
- stepmother
- stepfather
- other
Are there custody court orders?*
- Yes
- No
Upload documentation*
Drop files here or
Upload Birth Certificate*
Drop files here or
Upload Immunization Records here*
Please upload an updated copy of your child's current Immunization records.
Drop files here or
Upload Student Medical Recod*
Drop files here or
Upload Consent to Treatment Form*
Drop files here or
Parent/Guardian Information
Parent/Guardian #1 Information
Name*
First Last
Relationship to child*
Occupation*
Work Phone*
Cell Phone*
Email Address*
Texting?*
- Yes
- No
Mailing address*
Same as above

Street Address City State / Province / Region ZIP / Postal Code
Parent/Guardian #2 Information
Name*
First Last
Relationship to child*
Occupation*
Work Phone*
Cell Phone*
Email Address*
Texting?*
- Yes
- No
Mailing address*
Same as above

Street Address City State / Province / Region ZIP / Postal Code
Family Information
Sibling’s Information*
Name Age Grade School Attending
Additional Information
Has the student ever been recommended for special education?*
- Yes
- No
If yes, please explain*
Has the student been previously identified as qualifying for a gifted education program?*
- Yes
- No
If yes, please explain*
Billing Address*
Check if same as mailing address

Street Address City State / Province / Region ZIP / Postal Code
Contract of parents/guardian*
To the best of our knowledge, the questions on this application are answered completely and truthfully. I agree to assume the financial responsibility for the above student.
Parent’s Signature*
Date*
Date Format: MM slash DD slash YYYY
Consent for Pick Up

This form is designated to authorize specific persons who may regularly pick up your child from the premises of Chowchilla Adventist School. (Must be at least 18 years old)
Person #1*
Name Relationship Phone Number
Person #2
Name Relationship Phone Number
Person #3
Name Relationship Phone Number
Person #4
Name Relationship Phone Number
If you have an emergency and need someone not on this for to pick-up your child, please contact the school to provide your consent.
Is there anyone who is NOT authorized to take your child from school?*
- Yes
- No
If yes, please list and provide details*
Upload documentation/pictures*
Drop files here or
Parent’s Signature*
Date*
Date Format: MM slash DD slash YYYY
Registration Fee
Price: $150.00
Photo/Video Release Form
Permission to Use Student’s Photograph/Video: During the academic year, Chowchilla Adventist School may wish to use photographs/videos of our students in our school newsletters, brochures, in educational publications, social media or on our own school website. Any such photographs would highlight the students either demonstrating learning techniques or participating in approved school activities.
- I/We consent to the use of my child’s image in Chowchilla Adventist School publications.
- I/We DO NOT consent to the use of my child’s image in any Chowchilla Adventist School publications, except for the school yearbook.
Parent’s Signature*
Date*
Date Format: MM slash DD slash YYYY
Internet Acceptable Use Policy
To access Chowchilla Adventist School internet, I agree to abide by the following rules:
1. I will only be on the computer/internet when given permission by a teacher.
2. I will not access the school’s wireless internet through my cell phone, I-pad, or any other electronic device without a teacher’s permission.
3. When given permission to access the internet I will use it for educational purposes only.
4. I will not install any software.
5. I will not access You Tube, Facebook, gaming sites, or similar web sites.
6. I will tell the teachers or supervisor right away if I come across any information or pictures that go against school rules/guidelines.
7. I will not access or participate in any chat systems.
8. I will not threaten anyone online or use any improper language.
9. If I get a message with threats or improper language, I will tell the teachers and/or my parents right away.
10. I will follow school rules about when and how long I can be online, and the sites I can visit.
To access Chowchilla Adventist School internet, I agree to abide by the following rules: 1. I will only be on the computer/internet when given permission by a teacher. 2. I will not access the school’s wireless internet through my cell phone, I-pad, or any other electronic device without a teacher’s permission. When given permission to access the internet I will use it for educational purposes only. 3. I will not install any software. 4. I will not access You Tube, Facebook, gaming sites, or similar web sites. 5. I will tell the teachers or supervisor right away if I come across any information or pictures that go against school rules/guidelines. 6. I will not access or participate in any chat systems. 7. I will not threaten anyone online or use any improper language. 9. If I get a message with threats or improper language, I will tell the teachers and/or my parents right away. 10. I will follow school rules about when and how long I can be online, and the sites I can visit.
Check the box beside the statement:*
I have read, understand, and agree to abide by the terms of the Acceptable Use and Internet Safety Policy. Should I commit any violation or in any way misuse my access to Chowchilla Adventist School’s computer network and the internet, I understand and agree that my access privilege may be revoked, and school disciplinary action may be taken against me. I agree to follow the Acceptable Use and Internet Safety Policy.
Check the box beside the statement:*
As the parent or legal guardian of the above student, I have read, understand, and agree that my child will comply with terms of our school’s Acceptable Use and Internet Safety Policy. I understand that it is impossible for the school to restrict access to all offensive and controversial materials and understand my child’s responsibility for abiding by the policy. I hereby give permission for my child to use the computer network and the Internet.
Parent’s Signature*
Date*
Date Format: MM slash DD slash YYYY

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Name	Age	Grade	School Attending

Chowchilla Adventist School

Step 1 of 2

CAS Application Package

Student Information

Parent/Guardian Information

Parent/Guardian #1 Information

Parent/Guardian #2 Information

Family Information

Additional Information

Consent for Pick Up

Photo/Video Release Form

Internet Acceptable Use Policy

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