Scholarship Student Application

Entrance Date:*

Withdrawal Date:*

Choose A Scholarship*

Please choose what scholarship your child will be awarded.

Child's Name:*

First Last

Age:*

Birth Date:*

Address:*

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

Home Phone:*

Father's Information

Name:

First Last

Address:

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

Home Phone:

Work Phone:

Cell Phone:

Email:

Place of Employment:

Mother's Information

Name:

First Last

Address:

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

Home Phone:

Work Phone:

Cell Phone:

Email:

Place of Employment:

Pick-up Information

Child's Living Arrangements:*

Both Parents
Mother
Father
Other

Child's Legal Guardians:*

Both Parents
Mother
Father
Other

The Child may be released to the person(s) signing this agreement or to the following:*

Name	Address

Persons to contact in an emergency when parents cannot be reached:*

Name	Phone

Name of public or private school child attends, if any:*

Health Information

My child has the following special need(s):*

Child's Physician or Clinic's Name (Child's Primary Health Source):*

Phone:*

The following special accommodation(s) may be required to most effectively meet my child’s needs while at this school:

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns:

Parent Release for Media Recording

I, the undersigned, do hereby grant or deny permission to Bits & Bytes Academy to use the image of my child, as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Bits & Bytes Academy Web site.*

Deny permission to use my child’s image at all.
Grant permission to use my child’s image in the following ways (mark all that apply):

Limited usage: I want my child’s image used within the Bits & Bytes Academy setting only (not in the larger community).
Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within Bits & Bytes Academy or in the larger community. One example of this could be videos in parent education classes.
Limited usage: I want my child’s image used on printed materials only (no digital or video use).
Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by Bits & Bytes Academy for a variety of purposes and that these images may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images.

I agree that the information provided herein is true and correct to the best of my knowledge.

Parent/Guardian Signature:*

Date:*

Emergency Medical Authorization

Should my child suffer an injury or illness while in the care of Bits & Bytes Academy and the school is unable to contact me, I authorize the staff to secure such medical attention and care for the child as may be necessary. This may include, but is not limited to First Aid, CPR, or a trip to the hospital via ambulance. The staff of Arete Preparatory School will not personally transport a student to seek medical attention.
I agree to keep Arete Preparatory School informed of the changes in the telephone numbers, etc. where I can be reached.
Arete Preparatory School agrees to keep me informed of any incidents requiring professional medical attention involving my child.
Child’s primary source of health care is:

Physician/Clinic Name:*

Phone:*

Known medical conditions i.e. diabetic, asthmatic, drug allergies:

Parent/Guardian Signature:*

Date:*

Registration Fee*

Price: $130.00

Disclaimer: Registration fee refund determined by scholarship award.

Billing Information

Full Name:*

First Last

Email

Address*

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

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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Scholarship Student Application

Scholarship Registration

Father's Information

Mother's Information

Pick-up Information

Health Information

Parent Release for Media Recording

Emergency Medical Authorization

Billing Information

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