“Uniting the Love of Learning with the Love of God.”
2015-2016
New Student
Application Packet
Mr. Lawrence A. Swoope, Principal
539 S. Arlington Street
Akron, OH 44306
330-785-9116
www.acafirebirds.com
Student:_____________________________________Grade:__
Student:
Grade:_____________________
Why ACA? Here Are A Dozen Reasons
The Best Choice for Quality Education
 Creative, Disciplined and Safe Learning Environment
 Challenging, Comprehensive Curriculum
 Foreign Language and Computer Technology Training
 Greater than 90% High School Graduation and College
Enrollment Rate
 Graduates Excel At: C.V.C.A., Hoban, St. Vincent/St.
Mary, Walsh Jesuit High Schools
 Graduates Are Enrolled At Case Western Reserve
University, Morehouse, and Spellman College, Ohio State
University, and more
 High Scores on the PARCC Assessment Ohio Achievement
Assessment (OAA) Test and CAT scores (we match or
exceed scores from the State of Ohio, Akron Public, and
Akron Community Schools)
 Affordable Tuition
 Family Oriented School Hours
 Experienced, Professional, Compassionate, Staff and
Administration
 Students Are Prepared To Succeed and To Lead
 The Love Of Learning Is United With the Love Of God

MAKE ACA YOUR CHOICE!
Parental Agreement
Our Pledge to be the Chief Educator
Recognizing that parents have been given the charge by God to be the primary educators and
trainers of the child (Prov. 22:6, Ephesians 6:1) and. . . .
Recognizing that the Arlington Christian Academy exists to aid parents in the fulfillment of
that charge and..
Recognizing that children who have total parental involvement generally tend to experience
greater educational success.
We Pledge. . .
To maintain a home environment that stimulates health and well being in our child.
To attend three (3) Report Card Nights in which Curriculum Awareness Training sessions will be offered.
These sessions are offered by the Academy to help parents be more aware of the teaching process at
ACA and to become more adept in aiding their child with school assignments.
To provide a quiet place, consistent time and the necessary materials for my student to study.
To carefully review our child’s assignments before and after completion of such; giving
assistance where necessary, but maintaining the integrity of the process.
To become actively involved in the growth and expansion of ACA through (a) prayer and
affirmation, (b) active participation in the School and Home Organization (c) cooperating and
assisting with fundraisers, and (d) remitting the full tuition payments and other necessary fees
consistently and on time.
We accept our responsibility and entrust ACA to help fulfill our call to be the chief educator of
our child. And, therefore do pledge to uphold all of the above stated items to the best of our
ability
__________________________________________________________
Parent
______
Date
__________________________________________________________
Parent
______
Date
__________________________________________________________
______
Student’s Name
Grade Applying For
Parent Information
SECTION 1. CUSTODIAL PARENT INFORMATION: Adult(s) with whom student actually lives.
Please make sure information is completely filled out, current, and up to date!
Father’s ame_____________________________________________________________________________
Last
First
Middle
Address_______________________________________________Phone(
)_________________________
City/State/Zip
Place of Work___________________________Phone(
)_______________Hours________to__________
E-Mail____________________________________ Cell Phone (
) _________________________________
Please include if applicable!
Church Membership________________________________________________________________________
Mother’s Name____________________________________________________________________________
Last
First
Middle
Address_______________________________________________Phone(
)_________________________
City/State/Zip
Place of Work_______________________Phone(
)___________________Hours________to___________
E-Mail_____________________________________Cell Phone (
) ________________________________
Please include if applicable!
Church Membership________________________________________________________________________
How did you hear about the Academy? __________________________________________________________
Are the persons listed above _____Single _____Married _____Divorced
_____Separated
SECTION II. BIOLOGICAL PARENT INFORMATION: Other Parent involved with student’s rearing:
The information below is for the student’s biological _____Father_____Mother (check which applies)
Name____________________________________________________________________________________
Last
First
Middle
Address_______________________________________________________Phone(
Address
City/State/Zip
Place of Work___________________________Phone(
)__________________
)______________Hours________to____________
E-Mail_____________________________________Cell Phone(
)_________________________________
Please include in applicable!
Church Membership_________________________________________________________________________
Parent Information (continued)
Name of
Parent_______________________________________________________________________________
Name of Student_____________________________________________ Grade_____________________
Volunteer Clause
It is our desire to provide our students with the best of enriching learning opportunities and special events.
We accomplish this by soliciting from our families. Every Family is expected to fulfill the 10 hours of
mandatory volunteer service to the school. By signing below you are committing to fulfill our mandatory
volunteer hours.
X____________________________________________________________
X_________________
Parent/Guardian Signature
Date
2. What are your reasons for choosing Arlington Christian Academy to educate your student?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________
3. What methods of discipline do you find effective for your student?
4. Who cares for your student between the end of the school day and the end of the working day? ______
_____________________________________________________________________________________
5. What outside activities does your student participate? _______________________________________
_____________________________________________________________________________________
6. What responsibilities does your student have at home? _______________________________________
_____________________________________________________________________________________
7. Do you attend church regularly?
_________________________________________________________
8. What local church/place of worship are you now attending? __________________________________
_____________________________________________________________________________________
9. Are you a Christian_____________? If your answer is yes, how and when did you become a Christian?
Arlington Christian Academy accepts students from families of all religious denominations.
Date____________________________________ Signature of Parent ____________________________
Student Information
Please Type or Print: COMPLETE ALL SECTIONS OF THIS FORM.
Grade Applying For______
Name
_____________________________________________________________________Age____
Last
Name
Middle I.
Birth Date________________ Birth Place__________________________ Social Security #____
City/State
Address______________________________________________________Phone (
) ______
Street
City
Zip
School last
attended_______________________________________________________________________
Name of School
Address
Phone
What Public School would the student normally attend?
____________________________________________
Has student ever been suspended or expelled? Yes No Why?_________________________
_____________________________________________________________________________
Has the student received or been recommended to receive any diagnostic tests for learning or
behavioral disabilities, or for other special needs? Yes No List the results of previous
diagnostic tests below.
______________________________________________________________________________
______________________________________________________________________________
Does your student currently have an I.E.P.? _______________________________________
Has the student ever been recommended for grade retention? Yes No What
Grade(s)?_____________________________________________________________________
List any Grade(s) the student has actually repeated ________Current Grade Point Average_____
List Extracurricular Activities (School, Neighborhood, Church, etc.)
______________________________________________________________________________
List any Special Honors or Recognitions
Received_________________________________________________
______________________________________________________________________________
List any Special Needs i.e. (health, emotional, food,
etc.)____________________________________________
Recommendation and Student Essay
All applicants must obtain a recommendation for admission the Arlington Christian Academy. The recommendation
should tell about the applicant’s ability to succeed in the Academy. Recommendations may be obtained from sources
such as a Principal, Teacher, Pastor, Sunday School Teacher, etc.
Write the recommendation for the applicant below. Attach a blank sheet if more space is needed.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature of Person giving the Recommendation______________________________________________
Please Print Your Name_________________________________________Date_______________________
ESSAY FOR APPLICANTS
This should be completed by the Student (Parents may complete for K-2)
Why do you want to attend this school (Why do you want your student to attend this school)?
______________________________________________________________________________
______________________________________________________________________________
Tuition Rates and Schedules
The Arlington Christian Academy Board of Directors has approved the following Tuition Schedule for
the 2015-2016 School Year.
1. TUITION: The amount listed in the table below covers the following:
a.
b.
c.
d.
e.
Annual Tuition
Books
Lunch: Includes milk or juice
Registration Fee (paid with application, but will be applied to tuition)
Tuition Service Fee
PER STUDENT COSTS (The older student is always the first student)
Grade 1st Student
Year
K-4
$4548.80
5-8
$4687.20
2nd Student
Year
$4346.80
$4485.20
2. METHODS OF PAYMENT
A. Lump Sum Payment-The full tuition payment for one year must be paid on or before
August 10, 2015 Persons paying by this method will receive a 10% discount off the
total tuition.
B. Two Equal Payments-The tuition is paid in two equal payments. The first payment
is due on or before August 10, 2015. The second is due on or before January 12,
2016. No discount will apply.
C. Ten Month Payment Plan-The 1st payment is due August 10, 2015. The final
payment is due on May 12, 2016. Persons using this method MUST enroll in the
Electronics Funds Payment Program.
Month Due
August 10, 2015
September-May
1st Student K-4
454.80
454.80
2nd Student K-4
434.68
434.68
1st Student 5-8
468.72
468.72
2nd Student 5-8
448.52
448.52
3. BEFORE AND/OR AFTER SCHOOL CARE
Service
Before Care Only (7:30 am-8:40am)
After Care Only (3:15pm-5:30pm)
Per Student Cost
Yearly
Monthly
$850.00
$85.00
$850.00
$85.00
Before and After School Care
$1,700.00
$170.00
2015-2016 Tuition Contract
Read this Contract carefully. Complete a separate contract for each student enrolled. Please Print.
Name of Student for this Tuition Contract:
_______________________________Grade__________________
Name of Person responsible for the Contract:
___________________________________________________
I, the above named parent or guardian will be responsible for all tuition payments and fees for the above
named student. According to the Tuition Rates & Schedule Sheet my tuition cost for this student is
$__________ per year or $________ per month (10 months).
In addition to the tuition cost, my student will need the following (please check all that apply):
___ Before and After School Care at a cost of $170.00 per month (1,700.00 per
____Before Care Only at a cost of $85.00 per month (850.00 per year)
____ After Care Only at a cost of $85.00 per month (850.00 per year).
My total annual cost is $_____________ (Yearly tuition plus Before/After Care if applicable)
My total monthly cost is $____________(Monthly tuition plus Before/After Care if applicable)
Payment Methods
Method #1: One lump sum due on August 10, 2015(a 10% discount applies)
Method #2: Two equal payments due on August 10, 2015 and January 12, 2016.
Method #3: Ten equal monthly payments, the first being due August 10, 2015 and the last May 12, 2015.
I also understand that if I opt to pay in ten monthly payments that I must agree to pay a onetime
processing fee of $35.00 and to sign up for payment by Electronic Funds Transfer through Tuition
Plu$.
I choose to pay the tuition using Method# _______YOU MUST CHOOSE A PAYMENT PLAN.
I also am aware that should I opt to pay by Method #2 (semi-annual) that if I fail to pay the first
installment on time, my account will automatically be sent to Tuition Plu$ and I must pay monthly
installments. If I select to pay by Method #3 and fall in arrears by two months my account with Tuition
Plu$ will be automatically dropped and my child will be immediately dismissed from the Academy
until such time as the bill is paid current.
As the responsible party, I also understand that these tuition payments are due in full, even when the child
is absent or when school is closed for holidays or conferences.
AGREEMENT
I, the undersigned, have reviewed the above and fully agree to the terms therein. By affixing my
signature below, I am stating that I recognize this contract to be legal, and therefore to be a binding
financial and moral obligation. I therefore agree to abide by the conditions of this contract for the period
of time so stated above.
Signature of
Parent________________________________________________________Date____________________________
Signature of
Principal______________________________________________________Date____________________________
Tuition Plu$
P. O. Box 107
.
Akron, OH 44309-0107
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT
Payor Information
Primary Payors Last Name
First Name
MI
Spouses First Name (if applicable)
Street Address
City
State
Zip Code
Area Code
Daytime Phone #
Student Information
Last Name
MI
First Name
Last Name
MI
First Name
Last Name
MI
First Name
Payment Information
Payment Day
$
Month Payments Begin
# of Months
.
Payment Amount
Include all Students
1st Monday of Month
Please allow 10 days after Tuition Plu$ receives your request for automatic payments to be set up. It is your responsibility to
make any payments prior to setup. The school may adjust terms of this Agreement. A confirmation of terms will be mailed to
you.
I hereby authorize Tuition Plu$ to initiate debit entries on behalf of the school and my financial institution to charge my account
(as listed on attached voided check) for school related payments. Payments returned due to non-sufficient funds (NSF) may be
resubmitted. A $30.00 fee will be charged for NSF payments. These payments will be credited to the school. This
authorization is to remain in full force and effect until Tuition Plu$ has received written notification from me of its termination
and has reasonable opportunity to act on it (at least 3 banking days).
X________________________________________________________________Date________
PLEASE STAPLE YOUR VOIDED CHECK HERE
DO NOT USE A DEPOSIT SLIP
Before and After Care Agreement
This form must be completed for all students enrolling in the Before or After Care
Program
Name of
Student_______________________________________________________________Grade____
Birth Date _____________________________Age ____________Name of
Teacher_____________________
Parents/Guardian
Names______________________________________________________________________
Home Phone _________________Work #1 _______________________ Alt Phone
______________________
Cell Phone #1 __________________________________Cell Phone
#2________________________________
I hereby enroll my student, whose name appears above, in the (Please Check One):
_______Before School Care
_______After School Care
_______Before and After School Care
I promise to pick up my student by 5:30 p.m. every day as scheduled unless I advise otherwise,
but never later than 5:45p.m.except in a genuine emergency. A charge of $5.00 will be applied
to my bill at 5:31p.m., and each 15 minutes thereafter.
I agree to pay the monthly fee of $85.00 per month (850.00 per year) for Before or After School
Care or the monthly fee of $170.00 per month (1,700.00 per year) for Before and After School
Care. I understand there is no refund if my child is absent.
I understand that the program will consist of the following:
 Supervised Homework
 Educational TV
 Playtime
 Snack
I understand that there will be responsible adults present at all times to care for the students in
this program, and that every possible effort will be made to protect and assist the students in the
program. I hereby release ARLINGTON CHRISTIAN ACADEMY and the Before and After
School Care program supervisors from any other liability.
The following persons are authorized to pick up my child in the event that I am unable to do so:
_______________________________
_____________________
I understand that all rules, and commitments that apply to regular school will be enforced in the
Before and After School Program.
___________________________
____________
Signature of Parent/Guardian
In case of an emergency and I cannot be reached, please contact:
________________________________
Name of Individual and Relationship
Date
____________________________
Phone Number
Emergency Form
* Mandatory Fields
*Emergency
Contact#1_____________________________________________________________Phone___________________
Cell
Phone___________________
*Emergency
Contact#2_____________________________________________________________Phone___________________
Cell
Phone___________________
*Medical
Doctor__________________________________________________________________Phone_________________
Dentist_________________________________________________________________________Phone_________
___________
List any medical problem diagnosed:
__________________________________________________________________________
PART I TO GRANT REQUEST FOR EMERGENCY MEDICAL TREATMENT
In the event that the reasonable attempts have been used to contact the persons listed above have been unsuccessful,
I hereby give my consent for (1) the administration of any treatment deemed necessary by the above listed doctor
and /or dentist, or in the event the designated preferred practitioner is not available, by another licensed physician or
dentist, and (2) the transfer of the child to __________________________________________hospital or any
hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinion of the
two other licensed physicians or dentists concurring in the necessity for surgery is obtained before surgery is
performed.
Facts concerning the child’s medical history including allergies, medications being taken and any physical
impairment to which a physician should be alerted:
Signature of Parent/Guardian________________________________________Date__________________
PART II REFUSAL TO CONSENT
(DO NOT COMPLETE PART II IF YOU COMPLETED PART I)
I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring
emergency treatment, I wish for the Arlington Christian Academy authorities to take no actions or to:
___________________________________________________________________________
Signature of Parent/Guardian________________________________________Date__________________
FOR OFFICE USE ONLY
Date Received_______________
Time_________________
Interview Date_______________________
_____Accepted ________Letter Sent
______Denied _________ Letter Sent
Application Type:
EdChoice
Private Pay
Recommended Grade Placement:
Application Fee Paid
Check #
Cash
Amount__________________________
____________________
_______________
__________
Application Received By:
_____________________________________________________________________