HIGHVIEW CHRISTIAN ACADEMY
739 MAIN ROAD
CHARLESTON, MAINE 04422
Tel./Fax (207) 285-7978
Email: HCA_Office@yahoo.com
Website: www.highviewchristianacademy.org
APPLICATION FOR ADMISSION
STUDENT INFORMATION
Name:__________________________________________________________ Age: ________ Sex: ________
(Last)
(First)
(Middle)
Address: __________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Telephone: ____________________ Birthdate: ___________________ Birthplace:_____________________
(Home)
Grade last attended: ______________Any grade repeated: _______________ Grade to Enter _____________
School last attended: __________________________________________________________________________
City: _______________________________ State: ________________ Zip: _________________
Has applicant ever been expelled or suspended from school? ______________ When? ____________________
Why? __________________________________________________________________________
Does applicant have any physical or mental disabilities? (Diabetes, epilepsy, etc.) _______________________
FAMILY INFORMATION:
Name:
Home Address:
Phone (Home & Cell):
Email Address:
Occupation:
Employer:
Work Address/Phone:
Marital Status:
Religious Affiliation:
Family Church:
FATHER
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
MOTHER
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
______________________________________ _____________________________________
Father’s Signature
Mother’s Signature
______________
Date
PLEASE RETURN THIS FORM WITH THE REQUIRED $100.00 APPLICATION FEE.
$100.00 APPLICATION FEE IS NON-REFUNDABLE
MEDICAL HISTORY
Pupil’s Name ____________________________________ Birth Date __________________________ Sex ___________
Father’s Occupation ______________________________ Mother’s Occupation________________________________
Father’s Health __________________________________ If deceased, cause ___________________________________
Mother’s Health _________________________________ If deceased, cause ___________________________________
PAST DISEASES – (If your child has had any of the following, state age when they had them.)
Mumps __________________________ Diphtheria _______________________Polio ___________________________
Measles __________________________Scarlet Fever _____________________ Convulsions _____________________
Whooping Cough _________________ Rheumatic Fever __________________ Diabetes ________________________
Asthma __________________________Chicken Pox ______________________Hay Fever _______________________
Pneumonia _______________________Discharging Ears __________________Syphilis _________________________
Gonorrhea _______________________Heart Disease/Condition ____________Allergies ________________________
RECENT DISABILITIES – (Please check any one of the following noted recently.)
4 or more colds yearly _____________ Fainting Spells ____________________ Hearing Difficulty ________________
Frequent sore throats ______________ Abdominal pains __________________ Tires easily _____________________
Poor vision _______________________ Frequent urination ________________ Breath shortness _________________
Frequent leg pains _________________ Allergy __________________________ Hernia (rupture) _________________
Dizziness _________________________ Persistent cough __________________ Ringworm ______________________
Frequent sties _____________________ Speech difficulty __________________ Nose Bleeding ___________________
Dental defects _____________________ Crippling conditions _______________ Growing pains __________________
IMMUNIZATION RECORD – (please give date of each.)
Smallpox scar? ____________________ Whooping Cough _________________ Tetanus ________________________
Schick Negative ____________________ Diphtheria ______________________ Typhoid ________________________
Measles ___________________________ Polio ___________________________ HIB ___________________________
Does your child have a disability due to disease or accident? _______________________________________________
Has your child had a skin test for tuberculosis? ____________________________Date administrated _____________
Has he been associated with a tubercular patient? __________________________When? _______________________
PERSONAL RECORD – (Please answer all of the following.)
Is he/she shy? _______________________ Overactive? _____________________ Bite fingernails?_________________
Suck thumb? _______________________ Have excessive fears? ______________ Have temper tantrums? _________
Like school? ________________________ Play well w/others? ________________Eat Breakfast? _________________
When is his/her regular bedtime? __________________ When is his/her rising time? ___________________________
SIGNATURE OF PARENT__________________________________________ DATE __________________________
PHYSICIAN NAME ________________________________________________PHONE _________________________
SIGNATURE OF PHYSICIAN _______________________________________ DATE __________________________
(Please attach a copy of the child’s inoculation record/series.)
HIGHVIEW CHRISTIAN ACADEMY
STUDENT EMERGENCY INFORMATION
NAME OF STUDENT ________________________________________ TELEPHONE ____________________
HOME ADDRESS ____________________________________________________________________________
FATHER ___________________________________ MOTHER _______________________________________
EMPLOYER ________________________________ EMPLOYER ____________________________________
BUSINESS TEL. _____________________________BUSINESS TEL. _________________________________
CELL PHONE ______________________________ CELL PHONE ___________________________________
EMAIL ____________________________________ EMAIL __________________________________________
FAMILY PHYSICIAN ___________________________________ TEL._________________________________
ALLERGIES TO MEDICATIONS _________________________ BEE/INSECT STINGS _________________
MEDICAL INSURANCE CO & NUMBERS ______________________________________________________
WHOM TO CONTACT IF PARENT IS UNAVAILABLE _____________________ TEL. ________________
THE FOLLOWING PEOPLE HAVE PERMISSION TO PICK UP MY CHILD FROM SCHOOL _________
_____________________________________________________________________________________________
THE SCHOOL MAY GIVE THE FOLLOWING MEDICATIONS TO THE STUDENS DURING SCHOOL HOURS
_____________________________________________________________________________________
FIRST AID TREATMENTS (creams, sprays, cleaners, etc., sunscreen, bug spray)
_____________________________________________________________________________________________
DATE OF LAST TETANUS SHOT ______________________________________________________________
IN CASE OF ILLNESS OR ACCIDENT, I DESIRE TO BE CONTACTED. IF I CANNOT BE REACHED,
PERMISSION IS GRANTED FOR HIGHVIEW CHRISTIAN ACADEMY TO ARRANGE CARE FOR MY CHILD
ACCORDING TO THE SERIOUSNESS OF THE CASE.
I HAVE READ THE ABOVE INFORMATION. SIGNATURE OF PARENT OR GUARDIAN:
FATHER SIGNATURE ____________________________________________ DATE _____________________
MOTHER SIGNATURE ___________________________________________ DATE ______________________
HIGHVIEW CHRISTIAN ACADEMY
739 Main Road
Charleston, ME 04422
Tel: 207-285-7978
STUDENT LIABILITY RELEASE
STUDENT NAME: ______________________________________________________
Every activity sponsored by this school is carefully planned and adequately
supervised by mature adults. However, even with the best of planning and
precaution, unforeseen events can occur. By signing this form, the parent or
guardian agrees to assume all risks and hazards inherent in school-related activities.
They also agree to not hold this school or it’s employees or volunteer assistants
liable for damages, losses or injuries to the person or property undersigned. The
parents or guardians understand that they are signing for the minor listed on this
form and the signature is both for a medical and liability release.
“In the event that I cannot be reached in an emergency, I hereby give my
permission to the physician or dentist selected by Highview Christian Academy’s
leadership to hospitalize, to secure proper treatment, and or order and injection,
anesthesia, or surgery for my son or daughter as deemed necessary.”
PHOTO PERMISSION: Please indicate if your students photos can be used on
our website and for school promotions. All students have their photographs
printed in our yearbooks unless you specify otherwise.
________ I give HCA permission to use photographs of my child.
________ Photos of my child may not be used on the schools website or publications.
Parent or Guardian’s Signature
_______________________________________________Date ____________________
APPENDIX W
MPA TRANSFER WAIVER APPROVAL FORM
This form is to be processed when a student transfers from one school to another without a
corresponding change of legal residence of parent/guardian and wishes to participate in
interscholastic athletics within one year of the transfer (MPA By-Laws, Article III, Section 4).
The process and responsibilities are as follows:
1. Either PRINCIPAL may initiate the process by making this form available to the transferring
student and his/her parents/guardians for their signature (s). The initiating principal shall then
sign and forward this form to the second principal for his/her signature.
2. The second PRINCIPAL shall sign the form and forward it to the MPA Executive Director for
approval. All shall sign in a timely manner.
3. The transferring student is eligible the day this form is approved by the MPA Executive
Director or the Eligibility Committee.
I hereby certify that ____________________________________________ has been transferred from
(School) _____________________________ (State) _________________ (Country)______________
to Highview Christian Academy and is entering grade ______________ as of (date) ______________
and to the best of my knowledge the student has not transferred primarily for athletic purposes (see
MPA By-Laws, Article III, Section 4, Subsection A, Paragraph 3).
SIGNATURES:
Parent/Guardian _________________________________________________Date ________________
Student’s _______________________________________________________ Date ________________
Sending (Home Country) Principal’s ________________________________ Date ________________
__________ Do Certify
____________ Do Not Certify
Highview Christian Academy’s Principal’s ___________________________ Date ________________
_________ Do Certify
___________ Do Not Certify
WHEN ALL SIGNATURES ARE COMPLETED, IMMEDIATELY FAX THIS FORM TO THE
MPA AT (207-622-1513) OR MAIL TO: MPA, PO BOX 2468, AUGUSTA, ME 04338-2468
***FOR MPA USE ONLY***
This request for a waiver of the Transfer Rule is:
___ Granted by: MPA Executive Director_________________________________ Date __________
___ Referred to the Eligibility Committee: _____ Granted ______ Denied_______ Date___________
Notification sent to receiving school on ___________________________________________________
By: _________________________________________________________________________________
STUDENT RECORD RELEASE
RELEASING SCHOOL
School: ________________________________________________
Address: _______________________________________________
City: _______________________ State _______ Zip ___________
RECEIVING SCHOOL
HIGHVIEW CHRISTIAN ACADEMY
739 MAIN ROAD
CHARLESTON, ME 04422
PHONE/FAX – (207) 285 -7978
Dear Guidance Office:
My child(ren) have been withdrawn from your school. Please release ALL their academic and
health records to the above named receiving school.
STUDENT’S
NAME (last name first)
AGE
GRADE LEVEL AT TIME
OF WITHDRAWAL
Signature of Parent/Guardian ______________________________________
Signature of Receiving Principal ____________________________________
Highview Christian Academy
2013-2014 Tuition Schedule
*Tuition Payment Plan:
Tuition payments begin August 1, 2013 and continue until May 1, 2014 for 10 month plan or July 1,
2013 for 11 month plan. Late registration payments begin September 1, 2014 and end June 1, 2014.
Plan A is not available for those registering late.
Grades
1-12
1st child
2nd child
3rd child
4th child
Plan A
11 mnths/44 wks
$237.00/60.00
$200.00/50.00
$165.00/41.00
$128.00/32.00
Plan B
10 mnths/40 wks
$260.00/65.00
$220.00/55.00
$180.00/45.00
$140.00/35.00
Plan C
per semester
$1300.00
$1100.00
$ 900.00
$ 700.00
Plan D
full year
$2600.00
$2200.00
$1800.00
$1400.00
*Payments are due on the first day of the month. A late fee of $20.00 is charged for all payments
made after the 10th of each month.
Before/after school childcare is available from 7:00 am – 8:00 am and 2:30 pm – 5:30 pm.
Full childcare packages are available for before and after school care.
K-5 Tuition: The K-5 program offers half-day or full-day sessions for five days a week. Student
day ends at 2:45 pm. Before and after school care options are available. See preschool tuition
schedule.
K-3 and K-4 Tuition: The K-3 and K-4 programs offer several pre-school options. See preschool
tuition schedule.
The book fee is charged for all students and is due with the student’s first tuition payment.
Due to the increased cost of buying and replacing our book inventory we had to raise our book fees
for the 2013/2014 school year. Our new fees now include 2 shirts per student and are:
K-3 and K-4 - $175.00
K5 through grade 6 - $230.00
Grade 7 through 12 - $250.00
A graduation fee of $50.00 will be charged for senior students and a fee of $35.00 will be charged for
8th grade students and $25.00 for kindergarten students
A non-refundable registration fee of $100.00 is charged for new students. The re-enrollment fee is
$70.00 if done during the in-house weeks of registration. Late re-enrollments will be charged
$100.00.
Highview Christian Academy
Pre-school and Kindergarten Program
2013-2014 Yearly Fees
(Based on a 10 month or 40 week payment schedule)
K-3 and K-4
2 Half Days. . . . . . . . . . . . . . . . . . . .$28.00/week. . . . . . . . . . . . . . . . . . . .$1,120.00
3 Half Days. . . . . . . . . . . . . . . . . . . .$39.00/week. . . . . . . . . . . . . . . . . . . .$1,560.00
5 Half Days. . . . . . . . . . . . . . . . . . . .$60.00/week. . . . . . . . . . . . . . . . . . . .$2,400.00
2 Full Days. . . . . . . . . . . . . . . . . . . .$38.00/week. . . . . . . . . . . . . . . . . . . .$1,440.00
3 Full Days. . . . . . . . . . . . . . . . . . . .$55.00/week. . . . . . . . . . . . . . . . . . . .$2,200.00
5 Full Days. . . . . . . . . . . . . . . . . . . .$75.00/week. . . . . . . . . . . . . . . . . . . .$3,000.00
4 Day price is available upon request.
K-5
5 Half Days. . . . . . . . . . . . . . . . . . . .$60.00/week. . . . . . . . . . . . . . . . . . . .$2,400.00
5 Full Days. . . . . . . . . . . . . . . . . . . .$75.00/week. . . . . . . . . . . . . . . . . . . . $3,000.00
Fees
K-3 and K-4 Registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 70.00
K-3 and K-4 Book Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 175.00
K-5 Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$100.00
K-5 Book Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$230.00
Before/after school childcare - $3.00 per hour or $1,200 yearly fee for enrolled students.
The fee for drop-in students that are not enrolled in Highview is $5.00 per hour.
Care is available from 7:00 am – 8:00 am and from 2:45 pm – 5:30 pm.
HIGHVIEW CHRISTIAN ACADEMY
739 Main Road
Charleston, ME 04422
Tel./Fax 207-285-7978
FINANCIAL AGREEMENT
I, _________________________________, hereby agree that payment for my child’s educational
fees will be paid on the first day of each month or first day of the week. I realize if I should default
this agreement that he/she will be unable to return to school until payment is made.
Signed _______________________________________
Witnessed ____________________________________
Date ________________________________________
The scripture teaches us to be diligent in our financial responsibilities and that things are to be done
in order. This agreement is binding and is necessary to assure academic excellence and the future
of Highview Christian Academy.
Misc. Items
10¢
Frozen Food Items
$1.00
Dum Dums
Toaster Strudel (2 in bag)
Pancake/Sausage on a stick
Chicken Nuggets (4/bag)
Corn Dogs
Egg Rolls
Mozzarella Sticks (3/bag)
Pizza Roll Bites (6/bag)
25¢
Tootsie Pops
35¢
Gum (Juicy Fruit/Big Red)*
Airheads
Crackers
Small Slim Jims
50¢
Fruit Snacks
M & M Cookies
Gogurt
String Cheese
Assorted Chips (1oz or less)
Fruit Roll ups/Fruit snacks
Ring Pops
Handi-snacks
75¢
Pop chips
Large bags of chips (over 1 oz)
Microwavable Popcorn
Oreos
85¢
Assorted Candy Bars
Mentos
Nerd Ropes
Nuts or trail mix
Laffy Taffy
$1.00
Danish
Honey Buns
Cinnamon Rolls
Instant Lunch Noodles
Pop Tarts
Boxed chews
$1.50
Hot Pockets
Chimicangas
Quesadillas
Sausage/egg/cheese Croissants
$2.00
Pizza (Tony’s, Red Baron)
Nachos
Hot ‘n Spicy Noodle Bowls
Frozen Banquet Dinners
$2.50
BBQ Rib sandwich
Jumbo Angus Burger
$4.00
Tai Pai Frozen Dinners
Pagoda Frozen Dinners
Ice Cream Items
$1.25
Drumstick
Sundae Cone
$1.00
Klondike Bar
Snickers Bar
Twix Ice Cream Bar
$.75
Ice Cream Sandwich
Fudge Bar
Ice Cream Bar
$1.25
Tic Tacs
$1.00
Fresh Fruit – Whoopie Pies
Please note, not all
items are available
at all times!
Drinks
50¢
Sunny D
Juice Pouches
Small Water
Hawaiian Punch
Hot Chocolate
75¢
Can - Soda
Mountain Dew
A & W Root Bear
Dr. Pepper
$1.00
Small bottled juice
12 oz. Bottled Soda
Pepsi
Large Water
Small Gatorade
$1.25
Propel Water
16 oz. Bottled Soda
Flavored water
$1.50
Large juice
Chocolate Milk
Large Powerade
Large Gatorade
20 oz. Bottled Soda
Arizona Iced Tea
Large Vitamin Water
$2.00
Super Gatorade
School Supplies
Notebooks
Highlighters
Pens
Pencils
$1.00
$1.00
$ .25
$ .15
*Gum will only be sold to
Junior and Senior High
Students
_____AUGUST 2013______
S M T W T F S
1 2
3 4 5 6 7
8 9
10 11 12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 (27 28) 29 30
31 SEPTEMBER 2013
S M T W T F S
1 H ( 3) *4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30
2013/2014
School Calendar
22 days
S
3
10
17
24
NOVEMBER 2013
M T W T F S
(1) 2
4 5 6 7
8
9
H 12 13 14 15 16
18 19 20 21 22 23
25 26 27 28 29 30
16 days
DECEMBER 2013
S M T W T F
1
2 3 4 5 6
8
9 10 11 12 13
15 16 17 18 19 20
22 23 24 25 26 27
29 30 31
S
7
14
21
28
5
12
19
26
JANUARY 2014
M T W T
F
1 2 (3)
6
7
8
9 10
13 14 15 16 17
H 21 22 23 24
27 28 29 30 31
S
4
11
18
25
19 days
S
Highview Christian Academy
19 days
OCTOBER 2013
S M T W T F S
1
2
3 4 5
06 H 8
9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30 31
S
FEBRUARY 2014
M T W T F
2
3 4
9 10 11
16 H 18
23 24 25
739 Main Road
Charleston, ME 04422
(207) 285-7978
www.highviewchristianacademy.org
1st
2nd
3rd
4th
Quarter:
Quarter:
Quarter:
Quarter:
09/04–10/31 41 days
11/04-01/17 41 days
01/21-03/27 43 days
03/31-06/05 43 days
Student days
Teacher in-service
168 days
+ 5 days
Total days
173 days
* Denotes first & last day of school
H Denotes a Holiday
( ) Teachers in-service days
Italic Parent/Teacher Conferences
Vacation days or no school
___ Marks the end of the quarter
(Calendar may be subject to change)
2014
1/05
Teacher In-service day
1/17
2nd Quarter ends
15 days
1/20
Martin Luther King Day
1/21 & 1/23 Parent/Teacher Conf.
2013
2/12 – 2/14 Winter Carnival
8/27-8/28
Teacher flex days
2/17-2/21
February Vacation
9/02
Labor Day
3/27
3rd Quarter ends
9/03
Teacher In-service day
4/03
Parent/Teacher Conf.
9/04
1st day of classes
4/21-4/25
April Vacation
10/07
Columbus Day
5/26
Memorial Day
10/31
1st Quarter Ends
6/01
Baccalaureate
11/07
Parent/Teacher Conf.
6/05
4th Quarter ends
11/11
Veteran’s Day
6/05
End of the year fieldtrips
11/27-11/29
Thanksgiving Break
6/05
Last student day
12/23-01/05
Christmas Vacation
6/06
Teacher In-service day
6/07
Graduation – Class of 2014
S
1
5
6
7
8
12 13 14 15
19 20 21 22
26 27 28
15 days
S
M
2
9
16
23
30
3
10
17
24
31
MARCH 2014
T W T
4
11
18
25
5
12
19
26
F
S
1
6
7
8
13 14 15
20 21 22
27 (28) 29
20 days
S
M
6
13
20
27
7
14
21
28
APRIL 2014
T W T
1 2
3
8 9 10
15 16 17
22 23 24
29 30
F S
4
5
11 12
18 19
25 26
17 days
S
M
21 days
4 5
11 12
18 19
25 H
S
M
1
8
15
22
29
2
9
16
23
30
MAY 2014
T W T
1
6
7 8
13 14 15
20 21 22
27 28 29
JUNE 2014
T
W T
3
10
17
24
4
11
18
25
F
2
9
16
23
30
F
S
3
10
17
24
31
S
*5 (6) 7
12 13 14
19 20 21
26 27 28
4 days