INDIANA ELITE PREP BASKETBALL ACADEMY Application for Admission I hereby make application for the admission of my son to INDIANA ELITE BASKETBALL ACADEMY. In doing this, I subscribe to the regulations and to the spirit of discipline as set forth by INDIANA ELITE BASKETBALL ACADEMY. I also agree to the financial terms as explained in the current supplemental material. Student Information Student s Name: (FIRST) (LAST) Mailing Address City State Zip Code Social Security No. - - Date of Birth Home Phone Cell Phone Personal Information Age Height Weight Church Affiliation How did you learn of ELITE? Please check one of the following: U.S. Citizen or Naturalized Citizen International Student.Will you need an I-20? (Circle) Yes No (Applies to International students only) Country of Birth Country of Citizenship Academic Information Present Grade Grade Applying for Name of School now attending: From: To: Address: Street City State/Zip Code Principal s Name School Phone: Provide information for previous two schools: 1. School name Period attended Address
Principal Phone number Reason for leaving 2. School name Period attended Address Principal Phone number Reason for leaving List the current or most recent classes taken at present or previous school (ATTACH a copy of his most recent Report Card and Transcripts as well as any awards or honors received not sports related) 1. 2. 3. 4. 5. 6. 7. 8. Does the applicant have any special learning needs? or Individualized Educational Plan? If YES please provide a copy of all documentation pertaining to the students needs or assessments made. Parent / Guardian Information Relationship to student: Father \ Mother \ Grandparent \ Guardian Other: Name Address (If different) Social Security No. - - Occupation/Employer: Home Phone: Cell Phone: Work Phone: E-Mail: Relationship to student: Father \ Mother \ Grandparent \ Guardian Other: Name Address (If different) Social Security No. - - Occupation/Employer:
Home Phone: Cell Phone: Work Phone: E-mail: Personal Information It is critical when completing this application that the applicants are truthful and forthright with all information. Only with complete information can the determination be made of whether INDIANA ELITE BASKETBALL PREP ACADEMY and the student are compatible for each other, as some students may not succeed in this type of environment. Personal Behavior 1. Provide an explanation of why you want your son to attend INDIANA ELITE PREP BASKETBALL ACADEMY. 2. Has the applicant had any In-School or Out of School suspensions in the past 12 months or in the current school year? Yes No. If yes, write a detailed explanation for each instance providing when, where and why he was suspended. 3. Has the applicant ever been expelled or requested to withdraw from school? Yes No. If yes, provide a detailed explanation. 4. Has the applicant ever had discipline issues in the community? Yes No If yes, provide a detailed explanation. 5. Has the applicant ever been arrested, detained or ticketed by the police, juvenile authority, or any department of health or social services? Yes No. If yes, provide a detailed explanation. 6. Is the applicant currently under probation, court order, community service, or does he have any pending civil or criminal litigation? Yes No 7. To the best of your knowledge has the applicant used drugs or alcohol within the past 12 months? Yes No Provide an explanation. Medical Is the applicant currently taking any medications? Yes No. If yes, complete the information below. Has the applicant ever had psychological or psychiatric counseling for physical, emotional or behavioral issues, or suffered from any mental illness? Yes No. If yes, provide a full explanation of when the counseling occurred, reasons for therapy. Does the applicant have any physical conditions which would prevent him from participating in any
physical activities, the program, or that may cause harm to himself or someone else? Yes No. If yes, provide a full explanation. Application/Financial Agreement (*Please read and initial where indicated) I certify that the applicant is of good moral character and is not under the jurisdiction of a court. I pledge to the officials of INDIANA ELITE PREP BASKETBALL ACADEMY my support and cooperation in all that pertains to the welfare and honor of the school as a whole. I further certify that my child does not have a physical or mental condition that would be such that he could not perform the tasks of a daily routine or would cause him to harm himself or any other student. *Parent or Guardian Initials I have read and fully understand all of the financial information pertaining to the enrollment of my child in INDIANA ELITE PREP BASKETBALL ACADEMY. I also understand the enrollment deposit provided to IEPBA is non-refundable. *Parent or Guardian Initials I also understand that if my child should withdraw or be dismissed from IEPBA for any reason that I am still responsible for the full cost of the month regardless of date of withdraw or dismissal. Tuition is due on the 1 st say of each month, and no month for any reason will be prorated based on days. I further understand and agree that I am not entitled to any refund from INDIANA ELITE PREP BASKETBALL ACADEMY. ( All Payment, Donations, and gifts to IEPBA are non refundable) INDIANA ELITE PREP BASKETBALL ACADEMY Student Financial Break Down INDIANA ELITE PREP BASKETBALL ACADEMY tuition rates are $10,000 for 11 months. This tuition rate includes: Housing Food (two COOKED meals per day) Daily Transportation Team Gear (Uniform & Practice Uniform) Player must provide own team shoes Travel Gear (Each Student must pay one time fee of $65.00 sizing an customizing fee) Athletic Training Over 40 regular season games Collegiate level exposure ESL classes for non-native English speaking students (One time $155.00 enrollment fee) ACT/SAT prep courses (Each Student must pay own fees for testing) Academic Guidance An initial Down Payment of $2500 is due to IEPBA for each student. This paiement got to be done 60 days or more before beginning to IEPBA. Then student got to pay 1 st day of each months $750 during 10 month. Signature of Parent or Guardian who will be responsible for the applicants Financial Responsibility to IEPBA I understand that by providing my signature I am agreeing to the financial terms and conditions set forth by IEPBA. Failure to comply with the financial agreement will result in dismissal of the student from the IEPBA program. If any funds are owed to IEPBA we reserve the right to collect those funds through any legal avenue available to us by US Law or International Law. IEPBA will reserve the right to with hold any Transcripts, Film, Reference or assistance in locating and securing a college until all monies owed IEPBA have been paid. Name: (Print)
Name: (Signature) PLEASE USE WIRE TRANSFERT INFORMATION PAIEMENT: Ashley Combs INDIANA ELITE PREP - WEST END BANK, S.B. PO BOX 190 - RICHMOND - INDIANA - 47375 Account (replace IBAN) # 017107272106 Routing (replace BIC or SWIFT) # 274970814 INDIANA ELITE PREP BASKETBALL ACADEMY admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the Academy. It does not discriminate on the basis of race, color national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school administered programs.