Enrollment Application

Phone

This field is for validation purposes and should be left unchanged.

Date of Application(Required)

Campus(Required)

Choose the campus/program for which you wish to enroll. We can only process your application for the campus/program you choose.

KHCS Preschool (Year-round)

KHCS Grades K-7 (Fall-Spring)

CCA Grades 8-12 (Fall-Spring)

Camp Adventure (Summer Camp)

High School Summer Credit Recovery

General Information

Kingdom Heights Christian School

Dr. Terry Wright

Student Status(Required)

New Student

Returning Student (no changes in enrollment)

Returning Student with changes

Child's Full Name(Required)

First Middle Last

Child's Date of Birth(Required)

Child Lives With(Required)

Both Parents

Father

Mother

Guardian

Child's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Student Gender(Required)

Male

Female

School Last Attended(Required)

Please enter the name, address, and phone number of the school where we can obtain the child’s attendance and medical records. Enter N/A if there is no previous school attendance.

School Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School Phone(Required)

Grade Level Completed(Required)

Requested Student Start Date(Required)

Camp Adventure Weeks Selection(Required)

Please check the week(s) you are requesting for attendance in Camp Adventure. Our office will call you to confirm your choice(s).

June 1 – 5

June 8 – 12

June 15 – 19

June 22 – 26

July 6 – 10

July 13 – 17

July 20 – 24

July 27 – July 31

August 3 – 7

High School Summer Credit Recovery(Required)

Please check the week(s) you are requesting for attendance. Our office will call you to confirm your choice(s). We will invoice you based on the weeks you choose plus a $100 Registration Fee.

June 15 – 19

June 22 – 26

July 13 – 17

July 20 – 24

Extended Care

I need Extended Care (6:30 AM – 6:00 PM) for my child.

Name of Parent or Guardian Completing Form:(Required)

First Last

Address of Parent or Guardian (if different from the child's)

Street Address Address Line 2 City State ZIP Code

Father's Name

First Last

Father's Phone

Father's Email

Mother's Name

First Last

Mother's Phone

Mother's Email

Guardian's Name

First Last

Guardian's Phone

Guardian's Email

Custody Documents on File

Yes

Custody Documents

Drop files here or

Max. file size: 512 MB.

Please upload court documents indicating legal custody of the child.

Give the name, address, and phone number of the responsible individual to call in case of an emergency if parents/ guardian cannot be reached.

Name(Required)

Emergency contact name:

First Last

Relationship(Required)

Emergency contact relationship to student:

Phone(Required)

Emergency contact phone number:

Address(Required)

Emergency contact address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorized Individuals

I authorize the school to release my child to leave the school ONLY with the following persons. Please list name and telephone number for each. Children will only be released to a parent or guardian or to a person designated by the parent/guardian after verification of ID.

Name of Authorized Pickup Person(Required)

First Last

Phone(Required)

Name of Additional Authorized Pickup Person

First Last

Phone

Name of Additional Authorized Pickup Person

First Last

Phone

Religious Information:

Does your family attend church?(Required)

Yes

Church Attending:(Required)

Name of Church

Address

Street Address City State ZIP Code

Pastor's Name(Required)

First Last

Phone(Required)

Please indicate the family members who are Christians:(Required)

Father

Mother

Applicant

None

Consent Information

1. Transportation(Required)

I give consent for my child to be transported and supervised by the operation’s employees:

for emergency care

on field trips

to and from home

to and from school

2. Field Trips(Required)

I give consent for my child to participate in field trips.

I do not give consent for my child to participate in field trips.

Comments:

3. Water Activities(Required)

I give consent for my child to participate in the following water activities:

water table play

sprinkler play

splashing or wading pools

swimming pools

aquatic playgrounds

Is your child able to swim without assistance?(Required)

Yes

Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming?(Required)

Yes

Do you want your child to wear a life jacket while in or near a swimming pool?(Required)

Yes

4. Receipt of Written Operational Policies(Required)

5. Meals:

I understand and affirm that I will provide the following meals to be served to my child while in care (Check all that apply):

Morning snack

Lunch

Afternoon snack

6. Days and Times in Care:(Required)

My child is normally in care on the following days and times:

Day of the Week

7. Receipt of Parent’s Rights: I acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility.(Required)

Signature — Parent or Legal Guardian

I/We, the undersigned parent(s) or guardian(s), hereby consent to my child participating in all school-related activities sponsored by Covenant Community Schools (CCS), or associated ministries while enrolled in CCS. If my/our child has medical conditions, which may be relevant to a physician in the event of an emergency, I/we have listed them below. In the event that an emergency occurs, I/we may be reached at the telephone number listed below. If I/we cannot be reached, I/we hereby authorize school personnel to make emergency medical decisions for my child. If there are any activities I/we do not want my/our child involved in, I/we have listed them below.

I/WE UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON ALL SCHOOL ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I/We do hereby agree to hold Covenant Community Schools, other related organizations, and its agent and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my/our child or property, even injury resulting in death, which I/we now have or which may arise in the future in connection with the activity or participation in any other associated activities.

I/We expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Texas and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I/We further state that I/WE HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY/OUR OWN FREE ACT.

Authorization for Emergency Medical Attention

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

Name of Physician

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name of Emergency Care Facility

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Signature(Required)

I give consent for the facility to secure any and all necessary emergency medical care for my child.

Child's Additional Information Section

List any special needs that your child may have, such as environmental allergies, food intolerances, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:

Child Care Admissions Policies and Procedures

One of the following must be presented when your child is admitted to the child care operation or within one week of admission.

Health Care Professional’s Statement: I have examined the above named child within the past year and find that he or she is able to take part in the day care program.

Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.

Other

Health Care Professional's Statement

Max. file size: 512 MB.

Signed and Dated Affidavit

Max. file size: 512 MB.

Vaccination Record

Max. file size: 512 MB.

For additional information regarding immunizations, visit the Texas Department of State Health Services website at https://www.dshs.state.tx.us/immunize/public.shtm.

Signatures

Father's Signature(Required)

Mother's Signature(Required)

Legal Guardian's Signature(Required)