1
Athen Athens Christian
Preparatory
Academy
2013-14 Application for Enrollment
Applying for Grade: ________________
Office Use: Date Received: ____________
Age: _______ Date of Birth:
Fee Paid: ________ Testing Scheduled ________
_______________
STUDENT PERSONAL DATA
Name: _______________________________________ M / F
Home phone: _________________________
Address: __________________________________________
Cell phone: ___________________________
__________________________________________
Social Security#: _____-_____-________
__________________________________________
E-mail: __________________________________________
FAMILY DATA
With whom do you make your permanent home?  Parent/Guardian 1
Parent/Guardian 1:
 Mother
 Father
 Legal Guardian
 Other
________________________________________________
Last
First
Middle
Home address if different from student
 Parent/Guardian 2
Parent/Guardian 2:
Both
 Other
 Mother
 Father
 Legal Guardian
 Other
_______________________________________________
Last
First
Middle
Home address if different from student
________________________________________________
_______________________________________________
________________________________________________
_______________________________________________
________________________________________________
_______________________________________________
Home phone _____ - ______ - _____________
Home phone _____ - ______ - ______________
Cell phone
Cell phone
_____ - ______ - _____________
_____ - ______ - ______________
Work phone _____ - ______ - _____________
Work phone _____ - ______ - ______________
Employer ________________________________________
Employer _______________________________________
E-mail ___________________________________________
E-mail __________________________________________
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2013-14 Enrollment continued…
Applicant’s Name: ______________________________
If parents are divorced or separated, who has legal custody of the applicant? ___________________________________
(Name & Relationship)
NOTE: Copy of custody papers must accompany application
Who is financially responsible for the applicant’s tuition & fees? ______________________________________________
(Name & Relationship)
If the person(s) financially responsible is not listed as a Parent/Guardian, please provide the following:
___________________________________________________________________________________________
Home Address
City
State
Zip code
____________________________________________________________________________________________________
Home Telephone
E-Mail Address
Cell Phone#
Are you applying for financial aid?  Yes
 No If “Yes” contact us for additional forms
Testing:
Have you taken any of the following tests in the past 8 months? (check all applicable & provide copy of test scores with application)




OLSAT
ACT
SAT (Scholastic Assessment Test)
SLEP (Secondary Level Eng. Prof)
Education Information:
Present School
 SAT (Stanford Achievement Test)
 PLAN
 TOEFL (Test of Eng. Foreign Lang.)
 THEA
 Public
 Private/Parochial
School Name
District Name
Address
City
Head Master/Mistress or Counselor
Telephone#
 ITBS (Iowa Test of Basic Skills)
 PSAT
 SSAT (Secondary School Admiss. Test)
 Independent
 Home-schooled
Dates Attended
State
Zip
Fax#
Other Schools attended in the past three (3) years
Name
Address
City
State/Zip
Dates Attended
Name
Address
City
State/Zip
Dates Attended
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Parent questionnaire
Confidential Information: (Please attach extra paper if necessary.)
Has student ever skipped or repeated a grade?  Yes  No If yes, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
Has student been tested for any of the following?
 Speech/Language
 ADD/ADHD  Dyslexia
Give dates of testing and explanation of findings:
 Autism/Aspergers
 Bi-Polar
 Other ____________
Does student take any medication in relation to a learning difference?  Yes No
If yes, list all medication and known effects on the student. (i.e., better focus, headaches, queasy stomach)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Keeping in mind that students mature with time and guidance, has the applicant ever undergone any form of school
discipline?  Yes  No If Yes, explain:
__________________________________________________________________________________________________
Has student ever been suspended from school?
 Yes  No
Has student ever been expelled from school?
 Yes  No
Has student ever previously withdrawn from any school for any reason? Yes No
If yes, please explain the nature and consequence of the offense:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How do you think your student will benefit by attending Athens Christian Preparatory? Be as specific as possible:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
In what areas or activities do you hope to see your child participate in at ACP?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Are there any concerns that should be known by the school, which could either positively or negatively influence the
decision of the Admissions Committee?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are there any circumstances at home that might affect your student’s performance at ACP?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Church Information:
Church attended by:
Father
_____________________
Attendance:
 frequent
 occasional
Mother
_____________________
Student
________________________
frequent  occasional
 frequent  occasional
Does the student participate in a regular bible study or youth group? Please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Volunteer Talent Info:
Family involvement is critical to our school. Please indicate below the areas that may interest you or a family
member (i.e. grandparent, uncle, etc.) for the purposes of volunteer work. Many hands make light work!
I feel I have gifts and talents in the following areas: (check as many as apply)
 Fundraising
 Printed Materials
 Construction skills
 Cooking
 Internet research
 Construction
 Phone calling
 Photography
 Sports asst.
 Facilities for events
 Grant writing
 Web skills
 Trailer transport
 Business mentoring
 Bookkeeping
 Office support
 Gardening
 Thank you notes
 Organize chapels
 Prayer Warrior
 Art
 Organizing events
 Storage
 Field Trip driver
 Musician
 Data Entry
 Yearbook
 Teacher apprec.
 T-shirt design
 ACP jewelry coord
 Graphics
 Gathering materials
 Lunch room aide
 Advertising
 Seamstress
 Painting-non artistic
 Tournament organizer
 Event Decorating
 Handle T-shirt orders
 Registration aid
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Student Questionnaire
Name of Applicant (please print)
Date of Birth (mm/dd/yy)
Grade (applying for)
Age
Gender (M/F)
School Year (applying for)
Phone#
Student:
Please answer the following questions as thoughtfully as possible. We want to hear YOUR opinions, not those of your
parents or friends.
1. Which school subjects do you enjoy the most? Please explain.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. Which school subjects do you enjoy the least? Please explain.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3. Tell us about any favorite activities or hobbies you may have.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. How would your parents describe you?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
5. How would your friends describe you?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6. If you could change something about yourself, what would it be?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
7. List any sports you enjoy.
____________________________________________________________________________________
____________________________________________________________________________________
8. List any fine arts or other activities you enjoy.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Student Essay Requirement
Student Essay Requirements
Choose one of the following topics and write a 1-2 page essay. Hand write the essay first, then type it using
Font 12, Arial ,double spaced. Your handwritten draft MUST be attached for your essay to be accepted.
 Explain the impact of an event or activity that has created a change in your life or in your way of thinking.
 What makes you the interesting person that you are? (include qualities you like about yourself)
 Describe a person (other than your parents) that has influenced you a great deal and how they have
changed your life.
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Athens Christian Preparatory Academy
Athens, Texas
PASTOR/CHURCH LEADER REFERENCE
Applicant’s Name ________________________________________________
Grade Applying For __________
Parents __________________________________________________________________________________
Parents: In signing this form, you are waiving your right to see this form or any information contained
on this form. Any information shared in this form will only be used in the admissions process and in
serving the family as a part of our school community if admission is granted.
Parent signature: _________________________________________________________________________
Dear Pastor or Church Leader,
This student is seeking admission to Athens Christian Preparatory Academy, a Christ-centered, biblically based
school for grade 9-12. We expect our families to be committed to a distinctively Christian education and higher
academic standards. Our admission process looks at the academic, spiritual, and personal character of each
applicant and his/her family. You have been asked by the family to help us in this process. Please complete this
form and return it to us as soon as possible to the address listed on this page.
Christian Commitment:
 Evident & beyond question
Minimally involved
 No evidence of commitment
How long have you known the family and/or applicant? ______________________________________
Is the student active in the youth program, a bible study, service to church? Please describe.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
How would you describe the applicant’s relationship with:
His/her friends _______________________________________________________________________________________
Parents: _______________________________________________________________________________________________
Other authorities: ____________________________________________________________________________________
In your opinion, would this family benefit in a partnership with Athens Christian Preparatory?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
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Pastor/Church Leader-contd.
Are there any concerns that should be known by the school, which could positively or negatively
influence the decision of the Admissions Committee?
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Are there any other observations or information that you feel would assist the Admissions Committee
with their decision?
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Signed: ___________________________________________________________
Date: __________________________________
Pastor/Leader Name (printed): _________________________________________________________________
Position/Title: _____________________________________________________________________________________________
Church Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________________
Phone: ______________________________________________
On behalf of Athens Christian Preparatory Academy, thank you for assisting this family in the application process.
God Bless you and your ministry. Please mail or fax this form to:
Athens Christian Preparatory Academy
ATTN: Admissions
P.O. Box 2157
Athens, TX 75751
Phone # 903-386-0400
Fax# 903-264-9430
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Athens Christian Preparatory Academy
Athens, Texas
FAMILY FRIEND REFERENCE
Applicant’s Name ________________________________________________
Grade Applying For __________
Parents __________________________________________________________________________________
Parents: In signing this form, you are waiving your right to see this form or any information contained
on this form. Any information shared in this form will only be used in the admissions process and in
serving the family as a part of our school community if admission is granted.
Parent signature: _________________________________________________________________________
Dear Family Friend,
This student is seeking admission to Athens Christian Preparatory Academy, a Christ-centered, biblically based
school for grade 9-12. We expect our families to be committed to a distinctively Christian education and higher
academic standards. Our admission process looks at the academic, spiritual, and personal character of each
applicant and his/her family. You have been asked by the family to help us in this process. Please complete this
form and return it to us as soon as possible to the address listed on this page.
How long have you known the applicant and in what context?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please name two positive character traits that you appreciate and have observed in him/her.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please name one or more areas where he/she may need to work on character development in the maturing
process.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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Family/Friend Reference-contd.
In your opinion, would you say that he/she tends to:
 be easily influenced by peers (follower)
 passively stand on own beliefs/values
 actively influence his/her peers
Expand on answer if you wish.
______________________________________________________________________________________________
______________________________________________________________________________________________
Would you feel comfortable having your own children spend extended time with him/her?
Explain.________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
How would you describe the overall Christian character of this individual ?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Is there any additional information that feel would be helpful to the Admissions Committee?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Signed: ___________________________________________________________
Date: __________________________________
Name (printed): __________________________________________________________________________________________
Relationship to Family: _____________________________________________________________________________________________
On behalf of Athens Christian Preparatory Academy, thank you for assisting this family in the application process.
God Bless you and your family. Please mail or fax this form to: Athens Christian Preparatory Academy
ATTN: Admissions
P.O. Box 2157
Athens, TX 75751
Phone # 903-386-0400
Fax# 903-264-9430
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Athens Christian Preparatory Academy
Athens, Texas
FAMILY FRIEND REFERENCE
Applicant’s Name ________________________________________________
Grade Applying For __________
Parents __________________________________________________________________________________
Parents: In signing this form, you are waiving your right to see this form or any information contained
on this form. Any information shared in this form will only be used in the admissions process and in
serving the family as a part of our school community if admission is granted.
Parent signature: _________________________________________________________________________
Dear Family Friend,
This student is seeking admission to Athens Christian Preparatory Academy, a Christ-centered, biblically based
school for grade 9-12. We expect our families to be committed to a distinctively Christian education and higher
academic standards. Our admission process looks at the academic, spiritual, and personal character of each
applicant and his/her family. You have been asked by the family to help us in this process. Please complete this
form and return it to us as soon as possible to the address listed on this page.
How long have you known the applicant and in what context?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please name two positive character traits that you appreciate and have observed in him/her.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please name one or more areas where he/she may need to work on character development in the maturing
process.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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Family/Friend Reference-contd.
In your opinion, would you say that he/she tends to:
 be easily influenced by peers (follower)
 passively stand on own beliefs/values
 actively influence his/her peers
Expand on answer if you wish.
______________________________________________________________________________________________
______________________________________________________________________________________________
Would you feel comfortable having your own children spend extended time with him/her?
Explain.________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
How would you describe the overall Christian character of this individual ?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Is there any additional information that feel would be helpful to the Admissions Committee?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Signed: ___________________________________________________________
Date: __________________________________
Name (printed): __________________________________________________________________________________________
Relationship to Family: _____________________________________________________________________________________________
On behalf of Athens Christian Preparatory Academy, thank you for assisting this family in the application process.
God Bless you and your family. Please mail or fax this form to: Athens Christian Preparatory Academy
ATTN: Admissions
P.O. Box 2157
Athens, TX 75751
Phone # 903-386-0400
Fax# 903-264-9430
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Athens Christian Preparatory Academy
PERMISSION TO RELEASE SCHOOL RECORDS
In accordance with the provisions of the Family Educational Rights and Privacy Act of
1974, we have included the signed student Record Release Authorization form.
TO BE FILLED IN BY PARENT:
Permission is requested to release records of ________________________________________________
Born (student birth date) ______________________ who is or has been enrolled in your school.
Name of school: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
ATHENS CHRISTIAN PREPARATORY REQUESTS THE FOLLOWING INFORMATION:
 Transcript
 Official Administrative Record (name, address, birth date, grade level completed,
present grade, placement, class standing, attendance, etc.)
 Standardized Test Scores
 School Behavior Record/Teacher and Counselor Observation and Ratings
 Record of Extracurricular Activities
 Health Records
TO BE COMPLETED BY PARENT OR GUARDIAN:
I, the undersigned, grant permission for Athens Christian Preparatory Academy to receive
the requested information.
________________________________________________
__________________________
Signature of parent or guardian
Date of signature
Address:
Athens Christian Preparatory Academy
P.O. Box 2157
Athens, TX 75751
Phone: (903) 386-0400
Fax: (903) 264-9430
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Statement of Faith
ACPA Statement of Faith
Philosophy of Education
The educational philosophy of Athens Christian Preparatory Academy is that the truth of God permeates all
academic subjects and should not be taught in isolation. Education from a Biblical Worldview that focuses on
God, his infallible word, and His Creation, reveals to us his character and glorified nature. We are heirs to a
throne with Christ and therefore encourage the pursuit of excellence in academics, fine arts, and community
service.
Vision
Our vision is:




To instruct students of the relevance of God and his son Jesus Christ.
To create a Christian educational atmosphere that enables a student to become the most excellent
version of themselves.
To glorify God by nurturing the next generation towards living a lifestyle of the faithful.
To instill in each student the need for self-discipline, self-control, and an understanding of obedience.
Mission
To partner with families in creating legacies of faith.
Statements Defining Faith
1.
We believe the Bible to be the inspired, the only infallible, authoritative, inerrant Word of God
(2 Timothy 3:15, 2 Peter 1:21).
2.
We believe there is one God, eternally existent in three-persons - Father, Son, and Holy Spirit
(Genesis 1:1, Matthew 28:19, John 10:30).
3.
We believe in the deity of Christ (John 10:33);
His virgin birth (Isaiah 7:14, Matthew 1:23, Luke 1:35);
His sinless life (Hebrews 4:15, Hebrews 7:26);
His miracles (John 2:11);
His vicarious and atoning death (1 Corinthians 15:3, Ephesians 1:7, Hebrews 2:9);
His resurrection (John 11:25, 1 Corinthians 15:4);
His ascension to the right hand of the Father (Mark 16:19); and
His personal return in power and glory (Acts 1:11, Revelation 19:11).
4.
We believe in the absolute necessity of regeneration by the Holy Spirit for salvation because of the
exceeding sinfulness of human nature, that men are justified on the single ground of faith in the shed
blood of Christ, and that only God’s grace and through faith alone are we saved (John 3:16-19, John
5:24, Romans 5:8-9, Ephesians 2:8-10, Titus 3:5).
We believe in the resurrection of both the saved and the lost; they that are saved unto the
resurrection of life and they that are lost unto the resurrection of damnation (John 5:28-19).
5.
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6.
We believe in the spiritual unity of believers in our Lord Jesus Christ (Romans 8:9, 1 Corinthians 12:1213, Galatians 3:26-28).
7.
We believe in the present ministry of the Holy Spirit, by whose indwelling the Christian is enabled to
live a godly life (Romans 8:13-14, 1 Corinthians 6:19-20, Ephesians 4:30, Ephesians 5:18).
I understand and agree with Athens Christian Preparatory Academy Statement of Faith.
Parent Name (printed)
Signature
Date
Student Name (printed)
Signature
Date
NONDISCRIMINATORY STUDENT POLICY
Athens Christian Preparatory Academy admits students of any race, color, national, or ethnic origin to all the rights, privileges, programs, and
activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national or ethnic
origin in administration of its educational policies, tuition assistance programs and athletic and other school administered programs.
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Family/School Agreement
In signing this application, I (we)
1. Have answered the questions in this application to the best of my/our knowledge and ability. I/we also
understand that misrepresentation could invalidate the application process.
2. Agree with the school’s purpose, as well as its educational and spiritual objectives.
3. Am committed to providing a quality, Christian education for my child.
4. Agree with, and are supportive of, the school’s procedures for handling student discipline.
5. Am willing to provide continually updated immunization records for my student.
6. Am willing to have my student’s picture in the school’s yearbook and school advertising.
7. Am willing to have my family’s name, phone number, and address listed in the ACPA directory.
8. Acknowledge that I/we have read and understand the ACPA Handbook.
9. Agree to resolve conflicts with students, parents, staff, and administration as outlined in ACPA
handbook
10. Agree to meet my/our financial responsibility to ACPA according to the terms outlined on the separate
ACPA financial agreement.
11. Understand that this is an application only and that space will not be reserved for our child until the enrollment
process is completed and the registration fee is paid. (Registration fees are non-transferable and nonrefundable.)
In order for the enrollment process to begin the following MUST be provided:
 Signed Statement of Faith
 Enrollment Application-signed & $50 application fee
 Current Photo of Student
 Copy of Transcript(s)
 Copy of current report card (if mid-year)
Enrollment decisions will be finalized when all materials have been provided.
______________________________________________________________________________________________
Parent/Guardian Name (printed)
___________________________________________________________________________
Parent/Guardian Signature
Date
___________________________________________________________________________
Student Name (printed)
___________________________________________________________________________
Student Signature
Date
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Application Check List
APPLICATION FORMS
Enrollment Application Form **
Parent Questionnaire Form **
Student Questionnaire Form **
Statement of Faith Form **
RECOMMENDED FORMS
Pastor/Church Leader Reference Form
Two Personal Reference Form
Athens Christian Preparatory Academy
RECORDS RELEASE FORM **
Complete top portion, sign and date this form. Return this form with the Enrollment App.
OR, give this form to the student’s present school Registrar’s office requesting an “Official”
transcript be sent to ACPA (address on form)
ADMISSIONS TEST REQUREMENTS
Any of the accepted tests by ACPA.
OR schedule a test date with ACPA upon their receipt of the Enrollment Application Packet and
Application Fee
CERTIFICATES
A Birth Certificate OR Social Security Card
A copy of Student’s Drivers License (If applicable)
IMMUNIZATION RECORD
An up-to-date immunization record must be submitted before an applicant can be enrolled.
FEES **
A non-refundable fee of $50 payable to Athens Christian Preparatory.
PHOTO **
A recent photo of student
STUDENT ESSAY
Typed student essay accompanied by handwritten draft.
What Happens Next
1. Upon receipt of the Packet, the family will be notified.
2. When application is complete (all required and recommended documentation has been
received and testing complete), an interview with Admissions will be conducted and the
application will be reviewed by the Board.
3. Upon review, ACP will notify the family of the school’s decision.
4. If accepted, the family will be scheduled for orientation and registration.
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Athens Christian Preparatory Academy
EMERGENCY MEDICAL INFORMATION & AUTHORIZATION
Student name: __________________________________ Birth date: ______________ Sex: Male
Female
Address: _______________________________________ City: _________________ State: ______ Zip: __________
Home Phone: ______________________ Home FAX: _____________________ Grade entering: ________________
Mother’s Name: _____________________________ Day phone: ________________ Evening : _________________
Father’s Name: ______________________________ Day phone: ________________ Evening: __________________
Mother cell: ______________________ Father cell: ____________________ Student cell: ____________________
Local relative/friend emergency contact: __________________________ Relation: ___________ Phone#__________
Preferred local hospital: ___________________________________________________________________________
Local Physician: _______________________________________ Phone#: ___________________________________
Preferred Dentist/Orthodontist: __________________________ Phone#: ___________________________________
INSURANCE COMPANY (provide copy of card-both sides) _____________________________________________________
Policy #: ________________________
Group #: _________________________ Phone #: _________________
Primary Insured’s Name: __________________________________ SS# ___________________________________
Insurance Address: ____________________________________ City: _________________ State: ____ Zip: ________
MEDICAL ALERT INFORMATION -
Use additional sheet, if necessary.
ALLERGIES (MEDICATIONS, FOOD, SEASONAL):
________________________________________________________________________________________________________
CURRENT MEDICATIONS (PRESCRIPTION, OVER-THE-COUNTER, INHALER, EPI-PEN):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
CHRONIC MEDICAL/PSYCHOLOGICAL CONDITIONS: ______________________________________________________________
HISTORY OF SURGERY/FRACTURES/CONCUSSIONS: ______________________________________________________________
I do ______ do not ________ authorize any such treating physician or medical personnel to administer blood or blood products to my child.
Parents initials required.
19
ACPA EMERGENCY-CONTINUED
CONSENT FOR EMERGENCY TREATMENT
I hereby authorize Athens Christian Preparatory Academy (ACPA) and its representatives to consent and obtain
emergency medical treatment of my child, ___________________________________, in case of any illness or injury in
connection with a school activity or school trip. Such treatment will be administered by such physicians, other medical
personnel, hospitals, and/or clinics as may be selected by ACPA or its representative. I hereby assume responsibility for
such professional services.
________________________________________________
__________________________________
Signature of parent or guardian
Date
LIABILITY CLAUSE
Although ACPA intends to exercise responsibility in assuring a safe and enjoyable time for all students, accidents still
may happen. I understand that my signature on this permission slip means that I will not hold Athens Christian
Preparatory Academy or its sponsors liable in any way for accidents, injuries, or illnesses on/at any school-sponsored trip
or event.
_________________________________________________
__________________________________
Signature of parent or guardian
Date
MEDICAL RELEASE
I hereby indemnify Athens Christian Preparatory Academy and hold it harmless on behalf of myself; my spouse, if any;
and my child against any and all loss, damage (economic or otherwise), health care provider or emergency
transportation expense, or other costs and expenses, including but not limited to reasonable compensation or
employees, agents and counsel in defending itself against claims to liabilities, arising out of or related to the
administration or medication as requested and authorized herein, unless it is proven that the ACPA staff members or
volunteers acted willfully or in reckless disregard of my child’s health.
_______________________________________________
__________________________________
Signature of parent or guardian
Date
Subscribed and sworn before me by said affiant on this day, to certify which witness my hand and seal of office this
_______________ day of _____________________ 20_____
_______________________________________________________
SEAL
Notary Public in and for the State of Texas
My commission expires: ___________________________________
**IMPORTANT NOTICE**
This form MUST be returned to the ACPA office in order for the student to be enrolled at the school.