Crook County Christian School  * * * * * * STUDENT AGREEMENT  * * * * * I understand that I will receive a detention for the following violations:  1.                  Writing on walls, desks, tables or damaging or defacing any school             property (including textbooks).  Students and parents or guardians are             responsible for repair or replacing any damaged school property. 2.                  Lying, fighting, cheating or any other inappropriate behavior. 3.                  Violation of the Dress Code as outlined in the Handbook. 4.                  Chewing gum at any time while on school grounds. 5.                  Three tardies per quarter. 6.                  Overt displays of affection. 7.                  Three missing assignments per quarter.  '.. I understand that I can be suspended or expelled for the following violation:   . 1.            Disrespect or physical abuse shown to any faculty member. 2.            Use of alcoholic beverage, tobacco products, or drugs. 3.            Using profanity, immoral gestures, or pornography. 4.            Premarital sex or immorality. 5.            Bringing firearms, explosive devices, knives or weapons to school. 6.            Arson, stealing, vandalism or any other inappropriate behavior. 7.            Five or more detentions in one quarter.  '. . Students are expected to uphold these standards throughout their enrollment whether at home, school, or elsewhere. '  ALL DISCIPLINARY ACTION IS LEFT TO THE DISCRETION  OF THE SCHOOL BOARD AND ADMINISTRATION.   * * * * * * * * I have read the Crook County Christian School handbook in its entirety and the above statements, and agree to follow them if I am to be a part of CCCS.   '  ___________________________________     __________________________________ Signature of Student                                           Signature of Parent/Guardian  . .  __________________________________ Date  * * * * * * * * * * This agreement will be filed in your child’s cumulative folder. Please sign and return to the school at time of Admission Interview. * * * * *

** * * *   Crook County Christian School APPLICATION FOR ADMISSION * * * * * STUDENT INFORMATION   Student Name: ___________________________________________________________                                                                     Last                              First                             Middle Address_________________________________________________________________   City__________________________ State __________  Phone # ___________________   Age _______________                   Male _________            Female _________   Date of Birth ________________________ Place of Birth __________________________   Email Address_____________________________________________________________ * * * * * FAMILY INFORMATION:  ' Father’s Name _______________________________            Work # _________________   Employer ___________________________________            Occupation ______________   Mother’s Name ______________________________            Work # _________________   Employer ___________________________________            Occupation ______________   Marital Status ________________________________   Step Parent __________________________________            Is Child Adopted _________   Guardian’s Name _____________________________            Address ________________   City ________________________________________    State ______ Zip _________   Home Phone _________________________________            Work Phone _____________   Employer ___________________________________            Occupation ______________ * * * * * CHILDREN:  NAME                                                                                  GRADE                          AGE ________________________________________________________________________   ________________________________________________________________________   ________________________________________________________________________ . (1)

* * * * * EDUCATIONAL INFORMATION   Last School Attended ______________________________________________________   School Address ___________________________________________________________  ' Grade Completed ____________________________ Grade Entering ________________   Educational Difficulties:   ________________________________________________________________________   ________________________________________________________________________    * * * * * RELIGIOUS INFORMATION   Church Name _________________________________ Phone _____________________   Pastor’s Name ________________________________  Phone ____________________   Do you attend church on a regular basis? ______________________________________   In what area would you be interested in volunteering at the school?   Clerical ___ Tutoring ___ Lunchroom ___ Bulletin Boards ___ Other _______________ * * * * * STUDENT HEALTH HISTORY:  * You must provide a copy of your child’s immunization records upon registering. Please check the illnesses your child has had from birth to the time of entering school.  Include dates, if known, and important details: * ILLNESS                           DATE                       ILLNESS                            DATE  ' Allergy______________________________Scarlet Fever________________________ * Chicken Pox_________________________Poliomyelitis_________________________   Rubella_____________________________Rheumatic Fever_____________________       Mumps_____________________________Pneumonia__________________________   Whooping Cough_____________________Any Other___________________________   (2) . . * * * * *   EMERGENCY MEDICAL AUTHORIZAITON   Child’s Name _________________________________            Birth Date _______________   Social Security Number _________________________             Grade __________________   Parent / Guardian ______________________________            Phone __________________   Address ______________________________________          Work (Dad) _____________   City, State, Zip ________________________________           Work (Mom) ____________   * * * * *  Emergency Contact _____________________________  Phone __________________   Emergency Contact _____________________________  Phone __________________ * * * * *   Family Physician _______________________________  Phone __________________   Health Insurance _________________________________________________________        Group # _________________________    Identification # ______________________   Chronic Illnesses: _________________________________________________________   Allergies: _______________________________________________________________   Medication: _____________________________________________________________   Tylenol OK (Please Initial)  Yes _____   No _____   * * * * * I hereby certify that my child has permission to participate in all school-sponsored activities on or off school premises. * * * * *   I hereby authorize any member of the staff of Crook County Christian School to consent to any emergency medical treatment of the above child, which such person deems advisable if a parent or legal guardian cannot be located when the child needs such treatment. * * * * *   The above authorization will be effective for the 2011-2012 school year.    Parent / Guardian _____________________________________ Date _______________    (3)