Can Learn Christian Academy
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Can Learn Christian Academy
Enrollment Contract


12611 N. Wilson St. Mead, WA 99021                                                                      PO Box 9233 Spokane, WA 99209
(509) 362-3418                                                                                                                                   canlearnacademy@gmail.com 
 
                                                                                          
Today’s Date: _________________                                                                         Referred by: _________________________________
 
Please circle the level your child will be entering:    
      K                 Lower elementary             upper elementary                 Jr H.  

Student Information  
Full name: ___________________________________  Nickname: _______________________ Gender: _______   Date of Birth: _____________  SS#: _______________ Race: ___________________________ (CLCA does not discriminate on race,
color, national and/or ethnic origin, or disability in admissions, consulting and/or hiring practices.) 

Mother’s Name: __________________________________________  SS#: _______________________
Address: ______________________________________________________________________
Email: ____________________________________________   Cell phone: ______________________ 
Work phone: ________________________________ Occupation: _____________________________________________ 
Job title: ______________________________________________
 
Father’s Name: _____________________________________________ SS#: _______________
Home address (if not living in the home): ____________________________________________
 Cell phone: ________________  Work phone: ________________ Occupation: ___________________________
Job title: ______________________________
Marital status of parents:   married _____ divorced _____ separated _____  Single ____ If divorced or separated who has legal custody of the student? ___________________________
Sibling information:
Please list names and ages of all siblings:
______________________________     ___________________________      _____________________________

______________________________      __________________________        _____________________________ 

Does the family attend church regularly? ______   Religious beliefs: ______________________
Have you been involved in a private school before? ____________________________________
How did you hear about Can Learn Christian Academy? ________________________________
Why do you want your child to attend CLCA? _______________________________________________________________

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What are your main concerns about your child? ____________________________________________________________

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Is he/s adopted? ______   If yes: WA state, International? (Country) ________________________________________
At what age? _________________ At what age did he/s come to your home? _________________________________
Does child have any diagnosis or labels? ____________________________________________________________________

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Does child have any learning and/or attention struggles? ___________________________________________________

Does child have any emotional and/or social struggles? _____________________________________________________
Does child have any mental illness? __________________________________________________________________________
Is he/s hyperactive? _________  hypervigilant? ________ oppositional? ______________
As an infant did child spend much time on the floor (tummy time)? _____ yes  ____ No
Roughly how much time a day? _______________________________________________________________________________
How much time did they spend in walkers, saucers or lying on his/her back? ______________________________
Did you use an infant swing or rocking chair? ____Yes  ___ No
How old was child when he/s started rolling over? ______________
Did child belly crawl? ____ Yes   ___ No  if so, more or less than two months? ________
Did child creep (hands and knees)? ___ Yes    ___ No  if so, about how many months? ________
How old was child when he/s started walking? ________________
Any chronic medical conditions? ___________________________________________________
Does child need medication during the school day? ____________________________________
Has child had a comprehensive vision and/or hearing exam, other than at school? ____________
When and results? _______________________________________________________________________________________
If yes, may we have a copy? _______  
What are his/her talents and/or interests? ___________________________________________________________________

What are his/her academic strengths? _______________________________________________________________________

What are his/her weak subjects? ____________________________________________________________________________

List FOUR POSITIVE qualities about your child:
_____________________________________   ________________________________
_____________________________________  _________________________________
What is his/her attitude towards school and learning? ______________________________________________________

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Please provide a copy of any written reports your child may have such as:  
Psychological _____   Speech ____   Hearing _____ Vision _____    Physical Therapy _____ Occupational Therapy _____ Brain Mapping _____ (IEP’s will be in school recorders)
Does child prefer his/her left, right, or both? ___________ Which does he/s use most? _______
 
References:  Please list four people who know your child well; including the most recent teacher AND principal.  Many children ‘act’ differently in different environments. A negative reference does not mean we won’t accept him/her into the academy it just shows us how to help your child more.  References WILL be contacted!
Name                                              Phone                                 email                         Relationship ___________________________________________________________________________________________________________________

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School Information and Background
Please list ALL previous schools, grade & city/state and reason for leaving:
__________________________________________________________________________________________________________________

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Behavior & Discipline Information
Please share information concerning your child’s behavior pattern.  Don’t panic most of our students have been kicked out of more than one school and/or program.  To better understand your child, we must ask some personal questions.  Please be honest; we’re not judging you as a parent or your parenting skills but rather to know how to better serve both you & your child.  We would like to honestly know the situation and reasons.  Misrepresentation or withholding information may jeopardize your child’s enrollment.    

Is your child currently in counseling? ____ _______ With whom? _______________________________________________
Phone # ____________________ we will call to talk to counselor before admissions allowed.  

 Has your child ever received disciplinary actions at school?  Yes   No  School suspension? Yes   No  
Asked to withdraw by school? Yes   No   Expelled? Yes   No 
Please explain any ‘yes’ answers: ______________________________________________________________________________

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Has child witnessed or been victimized by prolong physical, mental, emotional, verbal, sexual
abuse and/or neglect?  Yes   No   Please explain: _____________________________________________________________

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Is your child aggressive and/or violent? Yes No
What are his/her triggers? _____________________________________________________________________________________
Is child self-abusive (injure, harm or put self in dangerous situations) Yes   No
Please explain: ________________________________________________________________________________________________

_________________________________________________________________________________________________________________
Does child have a history of making false allegations? Yes   No 
Please explain: ________________________________________________________________________________________________

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Is he/s verbally abusive…at home? Yes  No       at school? Yes  No      Both? Yes  No
Is child physically abusive…at home? Yes  No    at school? Yes  No     Both?  Yes  No
Whom does he/s usually target (go after)? __________________________________________________________________

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Does child have a juvenile arrest record? _____________ Has child been in a Crisis Intervention Program (CRC, residential treatment center (RTC), or Rehab? Yes  No 
Please explain: ___________________________________________________
What is the most challenging thing about parenting your child? ___________________________________________

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First year parents are REQUIRED to participate in monthly parent support-training meeting (held after the monthly pot luck) as part of your child attending the academy.  Are you ready to make a commitment to attend specialized parenting techniques that REALLY WORK?    Yes ___  No ___  

Release to take my child’s picture:
I, ____________________________________, give my permission for my child, ________________________________, picture to be taken.  These pictures may be used in the student’s file, website/Facebook and/or school brochure.

Signature: ____________________________  Date: _________________________________  

Permission for AVE (neuro-technology)
I, ________________________________, give my permission for my child, _______________ ____________________________, to participate in the AVE program.
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Signature: ____________________________  Date: _________________________________

Please tell us who MAY NOT pick your child up from school.  We understand cars break down, you become ill, etc. In those cases, if someone different then listed here needs to pick your child up please call/text to let us know & we WILL check their picture ID before releasing your child to them.  

Who IS ABLE to pick your child up?
Name                                                                Relationship                                       Contact #
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

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Who IS NOT ABLE to pick your child up? If you have a restraining order against someone we need a copy AND recent picture of that person. We DO NOT release any information about a child over the phone/email, etc.  
Name                                                           Relationship                                         Contact #
_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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Note: Our first priority is the physical, mental and emotional safety of all students and staff.  We have the right to refuse admission to or expel any child we feel would jeopardize the physical, mental and/or emotional safety & well-being of that child, other students and/or staff members.  

Please read the financial information page before signing.  

I, the undersigned, have read, understand and agree to abide by the tuition schedule and school policies.  I also understand there is an early withdrawal penalty if I withdrawal my child before the end of the school year (mid-August).
Parent/guardian Signature: _______________________________________     Date: _____________________

Parent/guardian Signature: ________________________________________      Date: _____________________


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