A MINISTRY OF UPPER ROOM CHURCH OF GOD IN CHRIST

The Upper Room Christian Academy exists to partner with families and churches to prepare students for biblical, academic and social excellence. A MINISTRY OF UPPER ROOM CHURCH OF GOD IN CHRIST 3330 Idlewood Village Drive Raleigh, North Carolina 27610 (919) 829-6250

Dear Prospective Parent, Thank you for your interest in Upper Room Christian Academy. We are a distinctively Christian school committed to educational excellence for each student in our program from 18 months old through 5 th grade. As a Classical Christian Education school, we are dedicated to preparing preschoolers for success in grade school and school students for effectively approaching middle school and beyond with confidence and excellence. We are a fully accredited academic institution through (SACS) Southern Association of Colleges and Schools and (ACSI) Association of Christian Schools International. Upper Room Christian Academy has had the privilege of providing Christian education to the Raleigh community for over 10 years and we have positively impacted thousands of students over that time. Our focus and commitment is to provide the finest quality of an academic experience possible; that instills each student with a Biblical worldview, Christian values and Character development to prepare them for success in the Kingdom of God and in the community as productive citizens. In addition to its comprehensive curriculum, URCA is known for its safe family environment, its caring qualified faculty and staff committed to excellence, providing a strong spiritual foundation, upholding high standards in academics and discipline and for its superior standards based athletic program. It is our desire to be an extension of the family by assisting parents in preparing students for Biblical, academic and social excellence. Thank you again for your consideration of this great school. We understand how vital and important the choice you make will be in deciding where your student will attend school. It is our desire to provide the information and support needed to assist you in this process. We invite you to take a tour of our facility to see our faculty and students actively engaged in the learning experience, URCA style. May the Lord bless you in your endeavor to provide Christian education for your children. It is a sacrifice that s worth it! Yours in Christian Service, Elder John Amanchukwu Executive Director

How to Apply Admission Policy & Procedure The Upper Room Christian Academy (URCA) 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 of the school. URCA does not discriminate on the basis of race, color, national and ethnic origin, the administration of its educational policies, enrollment policies, scholarships, athletic programs and other school-administered programs. URCA reserves the privilege of setting and maintaining our own standards of student conduct, dress, tuition, fees for services and scholarships. URCA reserves the right to refuse admission or to dismiss anyone who violates the school s standards set forth in the Parent/Student Handbook or as defined by the school board and or administration. URCA also reserves the right to change any policy as deemed necessary with or without notice. URCA is committed to providing the best possible education for every child accepted in our program. The admissions process consists of collecting and receiving an application, previous school records, teacher recommendations, interviews, assessing the needs of the student, and willingness of the family to partner with the school s mission and vision. Please use the admissions process checklist to ensure that all necessary information is collected. Entrance Requirements Students seeking admission to URCA may be required to take an entrance test to determine proper grade placement. Administration may accept recent standardized test scores from another school or psychologist if available. It will generally be necessary for a student to score on or above the grade level being requested. If entrance tests are required, they will be scheduled by our school Principal. Students applying for entrance to our Kindergarten program should be turning 5 years old on or before October 31 st. We have completed the application. What s next? After the application is processed, the parents/guardians will be contacted by the Admissions Office to schedule an interview with the prospective family and student(s) to finalize the process. The interview provides an opportunity to fellowship with one another, to hear your families goals and aspirations, and to evaluate how we can best serve your student(s). Academy Administrators will review the application, test scores, transcript/grade reports and interview information. Prospective student placement or diagnostic testing will be administered. Applicants will be notified of enrollment status by mail or by phone. Once accepted, applicant must pay $90.00 to complete the registration fee. After the student(s) has been accepted, the Admissions Office will issue the Welcome Packet and explain the billing/payment process with the family. A child will be officially enrolled and given a class assignment: After he/she is accepted After the annual registration fee of $150.00 has been paid After the annual resource fee of $300 has paid After the first month s tuition has been paid We look forward to meeting your family, and will be in prayer with you as you embark upon your choice for Christian education.

Listed below are the required steps for admission into the Upper Room Christian Academy. A student will not be officially enrolled until all necessary documents have been received. Interested families are to submit a completed application with the $60.00 application fee. The application fee is non-refundable and will be applied to the registration fee of $150.00 if the student is accepted into the school. Call the school to schedule a tour of URCA or you may do so at www.urcap.org Complete and sign an application for each child applying - both parents are required to sign Application Processing Fee - attach a check made payable to URCA for the non-refundable amount of $60.00. Birth Certificate Must be an official copy Student Immunization Records Due by Sept. 1 st for all new students Students turning 12 years old must provide documentation showing a DTAP immunization within the past four years. Report Cards previous 2 years Admissions Process Checklist Records Request Form Complete, sign and return with the application Pastor s Reference must be signed and dated by a parent or guardian, then completed by your church pastor. The form must be mailed or faxed back to URCA from the pastor Teacher s Reference a teacher of the applicant must complete the form and mail or fax back to URCA Kindergarten Health Assessment - completed by a doctor within 30 days after the start of school Student Handbook Parents are encouraged to review the Student Handbook to become familiar with our established policies and procedures. An electronic copy of the handbook can be found at the www.urcap.org. Statement of Cooperation Complete, sign and return with the application SMART Tuition Enrollment Form Complete, sign and return with the application After your application is processed, you will be contacted by the admissions office to schedule an interview with you and the prospective student (s) to finalize the process. Initial Fees - A child will be officially enrolled and given a class assignment after the Annual Registration Fee of $150, Annual Resource Fee of $300 and the first month s tuition has been paid. All fees are non-refundable. Please be sure to follow these guidelines to avoid delays in the application process. Please return to URCA Admissions Office at: 3330 Idlewood Village Drive Raleigh, North Carolina 27610 or fax to (919) 829-6193

ELEMENTARY TUITION and FINANCIAL INFORMATION 2013/14 Tuition Cost: The cost of tuition is represented by the Full Amount Due. Payment Options: For grades K-5 we have devised 2 payment options: 10 month payment plan- with the first tuition due August 1st 12 month payment plan-with the first tuition payment due June 1st Late Fees: All monthly payments are due to Smart Tuition by the scheduled due date. A $35.00 late fee will be assessed to your account for all payments that are past due. All past due tuition and late fees must be paid if your student is to remain in the school. Dishonored Payments: A fee of $25 will be applied to your account for any failed auto-debit and failed check payments. Your bank may impose additional fee. Tuition Refund: There will be no refund for absences from school. Exceptions may only be made in the case of hospitalization of your child with a serious illness. A doctor s note will be required. Suspension for Non-Payment: Elementary students will not be allowed to attend class when their accounts are over 30 days delinquent. Students are subject to dismissal if their account is not brought current or an acceptable payment arrangement is not made within 60 days. Students suspended more than twice within a school year for non-payment may be dismissed from URCA. Application Processing Fee: $60.00 per student for new students only (non-refundable). Due with application. Annual Registration Fee: $150.00 per student due upon acceptance or re-enrollment (non-refundable) Annual Resource Fee: $300.00 per student (non-refundable) Due in full before 1st day of class. Grade Level Full Amount Due (receive 3% discount if paid in full 10 Month Pymt Plan August-May 12 Month Pymt Plan June-May K-5 $5100 $4947 w/discount $510/monthly $425/monthly Extended Care Rates Available Upon Request Available Upon Request Available Upon Request ELEMENTARY Multiple child discount: Upper Room Church discount : Church discount: **10% for 2nd student, 15% for 3rd student and each additional student **10% 1st student, 15%for each additional student ** 10% per student-must have at least 10 students to qualify **(not applicable with any other discount)

Additional Financial Information: Return Check Fee: A fee of $35 will be charged for all returned checks. This fee will be automatically billed to your account when a return check is received. SMART Tuition: If you choose to pay monthly, all tuition payments are made to SMART Tuition. All families must complete a SMART application upon enrollment. Information and sign-up for SMART is located on the URCA website, www.urcap.org. Tuition Assistance: Tuition Assistance awards are determined according to a family s demonstrated need based on information collected by SMART Tuition. SMART is a third-party agency that makes financial needs assessments for schools. SMART uses information supplied by the applicant to assess financial need. Applications can be fill out online from the SMART Tuition link or an application can be picked up in the Administrative Office. The decision to provide assistance is determined solely by URCA using the assessment from SMART and other factors as deemed necessary. Each award is made in the form of a tuition discount, is for one year only, is based on availability of tuition assistance funds and is awarded to returning families first. Applications submitted after that date will be reviewed and awards will be based on the amount of assistance remaining. New students must be accepted by URCA before tuition assistance can be requested. Early Withdrawal: The school budget and teacher contracts are set based on students being enrolled for the entire school year. An early withdrawal of a student creates an unexpected hardship on the school and an opening that may not be filled. Therefore, students who are withdrawn before April 1st will be accessed a fee of $500 per child. In addition, any paid fees are non-refundable and all books and supplies are forfeited. InfoDirect: InfoDirect is a feature designed to help connect the school to the home by means of a secure Internet connection. With a user ID and password, parents will be able to check lunch menus, upcoming events, get directions to a sporting event and download homework assignments. Annual Fund: Each family is requested to give a yearly tax deductible gift to the Annual Fund. These contributions will provide additional financial resources to be used to expand and improve the programs and services of URCA. It is very important that every family participates and we ask that you pray about what amount to give. No Billing Statements: URCA does not send statements or invoices. All billing is done through Smart Tuition. Records: Records will not be forwarded to another school until all financial obligations to the school are met. Report cards must be held by the school at the end of the year if there is an unpaid balance. Report cards will not be issued if you have an overdue balance. Early Arrival/After School Care: If your students attend before or aftercare on a monthly basis, the monthly fees will be added to your SMART Tuition account. Payments are due in advance at the beginning of the month of service. Families will be charged $1.00 for every minute a child remains in aftercare pass 6:00pm. Meal Program: URCA offers a student choice meal program. Students have the option of ordering lunch from one of URCA s vendors or bringing a nutritious bag lunch from home. Vendor meals must be ordered a month in advance through www.orderlunches.com which offers a secure, fast and easy to use, online ordering solution that provides the ability to view your school s meal menu, order, pay, and manage your meals orders online.

ENROLLMENT APPLICATION Date of Application: Number of Applicants: How did you learn about Upper Room Christian Academy? Applicant: New Student Returning Aftercare: Yes No Early Arrival: Yes No Payment Plan: Full Payment 10 Month 12 Month (10 and 12 month payments received by SMART Tuition) Applicant Information Applicant 1 Name: First Middle Last Grade Applying For: K 1 2 3 4 5 Male: Female: Preferred Name: Birth:(Month/Day/Year) / / Place of Birth: Citizenship: US or Other Last School Attended: Applicant 2 Name: First Middle Last Grade Applying For: K 1 2 3 4 5 Male: Female: Preferred Name:

Parent/Guardian Information Father s Name: Street Address State: City: Zip Code: County: Home Phone: Cell Phone: Work Phone: Mother s Name: Street Address State: City: Zip Code: County: Home Phone: Cell Phone: Work Phone: Father s Email Address Mother s Email Address Father s Employer: Mother s Employer: Employer s Street Address: City: State: Zip Code: County: Paternal Grandparents Name(s): Address: City: State: Zip: Phone: Employer s Street Address: City: State: Zip Code: County: Maternal Grandparents Name(s): Address: City: State: Zip: Phone: *If a parent has primary custody, URCA requires copies of the custodial legal documents to be provided to the Admissions Office with application. The applicant(s) live with: Both Parents Father Mother Grandparent(s) Other Is Parent(s) deceased Specify: Parents marital status: Who has custody: Who Receives Mail: Who pays tuition: Church Membership: Pastor s Name: How long Active Member: Street Address: City: State: Zip Code: Father: Christian? Yes No If yes, briefly state your salvation experience. Mother: Christian? Yes No If yes, briefly state your salvation experience. Emergency Medical Information Emergency Contact: Best Phone Contact:

Scholastic Information Applicant 1 Previous Level of Academic Performance: ( ) Excellent ( ) Above Average ( ) Average ( ) Below Average Has student ever repeated a grade: ( ) No ( ) Yes What grade: Has student ever been expelled, suspended, or refused admission to another school? ( )No ( )Yes If yes, please identify and explain. Has student ever had any disciplinary difficulties? ( )No ( )Yes If yes, please identify and give details Address of Previous School: Name of Contact Person Phone: Are there any reasons that the student cannot participate fully during normal school activities, including athletics or extracurricular? ( ) No ( ) Yes Please explain: Are there any special factors, conditions, learning differences, including any special medications or allergies affecting the student of which the school needs to be informed? ( ) No ( ) Yes Please explain: Applicant 2 Previous Level of Academic Performance: ( ) Excellent ( ) Above Average ( ) Average ( ) Below Average Has student ever repeated a grade: ( ) No ( ) Yes What grade: Has student ever been expelled, suspended, or refused admission to another school? ( )No ( )Yes If yes, please identify and explain. Has student ever had any disciplinary difficulties? ( )No ( )Yes If yes, please identify and give details

Applicant 3 Previous Level of Academic Performance: ( ) Excellent ( ) Above Average ( ) Average ( ) Below Average Has student ever repeated a grade: ( ) No ( ) Yes What grade: Has student ever been expelled, suspended, or refused admission to another school? ( )No ( )Yes If yes, please identify and explain. Has student ever had any disciplinary difficulties? ( )No ( )Yes If yes, please identify and give details Address of Previous School: Name of Contact Person Phone: Are there any reasons that the student cannot participate fully during normal school activities, including athletics or extracurricular? ( ) No ( ) Yes Please explain: The Upper Room Christian 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 of the school. URCA does not discriminate on the basis of race, color, national and ethnic origin the administration of its educational policies, enrollment policies, scholarships, athletic programs and other school-administered programs. We reserve the privilege of setting and maintaining our own standards of student conduct, dress, tuition, fees for services and scholarships. The school reserves the right to refuse admission or to dismiss anyone who violates the school s standards set forth in the Parent/ Student handbook or as defined by the school board and or administration. The school also reserves the right to change policy as deemed necessary. Are there any special factors, conditions, learning differences, including any special medications or allergies affecting the student of which the school needs to be informed? ( ) No ( ) Yes Please explain:

STATEMENT OF COOPERATION FINANCES: We understand it is necessary that parents pay tuition for the amount stated on the Tuition and Financial Information statement. If tuition payments and fees are not received by the due date of each month, a $35.00 late charge will be added to the account. Tuition that becomes 30 days past due will result in the student being withheld from attending school until such amounts due to URCA are made current. If the account is not brought current with 60 days of the due date the student may be dismissed from the school. A fee of $35.00 will be charged for each returned check. All tuition payments are made via electronic funds transfer, by check or credit card to SMART TUI- TION. The full month's tuition is due for any month in which the student attends one school day. All fees are due in full and are nonrefundable. Refunds are for tuition only and will be made on accounts that are paid beyond the current month. All fees are non-refundable. EARLY WITHDRAWAL FEE: A withdrawal fee of $500.00 must be paid if student is withdrawn prior to the end of the school year. Records will not be released until the account is paid in full to include the Early Withdrawal Fee. SCHOOL ACTIVITIES: We give permission for our child(ren) to take part in any and all school activities, class field trips, including sports and school sponsored trips away from the school premises and absolve the school from liability to us or our child because of any injury to us or our child at school or during any school activity. In case of emergency or serious illness, we request the school contact us first. If we are not available, please contact the designated emergency contact(s). If the emergency contact(s) cannot be reached, the school has our permission to make whatever arrangements deemed necessary for our child(ren)'s treatment. If the emergency is life-threatening and we cannot be reached, the physician has permission to act accordingly absolving the school of any liability. This statement of cooperation will serve as a blanket permission slip from my child s date of enrollment unless otherwise notified by me the parent or legal guardian. We understand that in order to participate as a volunteer we must abide by the guidelines set forth in the volunteer policy and have all necessary forms completed. RIGHTS OF USE AND REPRODUCTION: We authorize URCA or anyone authorized by URCA, to use and reproduce all audio and video tapes and photographs which URCA takes of our child(ren) or any family member produced for school literature, advertisements, and promotional purposes without further compensation. All copies, masters, negatives, pictures and proofs shall constitute URCA property, solely and completely. DISCIPLINE: We believe discipline is a necessary aspect of our child(ren)'s education. We give permission for our child(ren)'s teacher and/or administration to make and enforce classroom regulations in a manner consistent with Christian principles and discipline as set forth in Scriptures and outlined in our handbook. We understand that we have the responsibility to actively support the authority, philosophy, objectives, policies, procedures, and discipline of the school as established by the School Board. We understand that we may be called and required to come discipline our child. I agree to do this and understand that failure to fulfill this requirement may result in losing the privilege for my child to be served by Upper Room Christian Academy. I have been personally informed of these procedures. PARENTAL COMMITMENT: We agree that we will in no case complain to other parents, but will register only necessary complaints with the teacher or administration following the Matthew 18 principle. We pledge our full cooperation to keep doctrinal controversy out of the school. We agree to support the school with our prayers and positive attitude. We understand that if at any time the school determines, in its sole discretion, that our actions do not support the ministry, or reflect a lack of cooperation and commitment to the home and school working together, the school has the right to request the withdrawal of our child(ren). Admission to Upper Room Christian Academy is a privilege and not a right. It is a privilege granted with the understanding that students will desire to live as Bible-believing, consecrated Christians. Conduct exemplary of developing young Christians is expected. Drinking alcoholic beverages, using marijuana or other illegal drugs, smoking, profanity, disrespect for authority or property, improper sexual behavior and abuse of others by us, our child or any person visiting the school on our behalf are prohibited on our campus and discouraged in the home and private time away from school. Inappropriate clothing and playing loud music when visiting the school are not allowed. This applies to school and non-school related social activities where unacceptable behavior would have an adverse effect on the testimony of the school. As a URCA family, we will commit to the principle of the sanctity of marriage between a man and a woman. FAITH STATEMENT: The general nature and object of Upper Room Christian Academy shall be to conduct an institution of learning for the general education of youth in the essentials of culture and its arts and sciences, giving special emphasis to the Christian faith and the ethics revealed in the Holy Scriptures that young people may be prepared spiritually, academically and socially for every good work. We believe in accordance with the Upper Room Church that the Bible is the inspired and only infallible written Word of God; that there is One God eternally existent in Three Persons: God the Father, God the Son, and God the Holy Spirit; we believe in the Blessed Hope, which is the rapture of the church of God, which is in Christ, at His return; that the only means of being cleansed from sin, is through repentance, faith in the precious Blood of Jesus Christ and accepting the gospel according to Romans 10:9-10; that regeneration by the Holy Ghost is absolutely essential for personal salvation; that the redemptive work of Christ on the Cross-provides healing for the human body in answer to believing prayer; that the baptism in the Holy Ghost, according to Acts 2:4 is given to believers who ask for it; and we believe in the sanctifying power of the Holy Spirit, by whose indwelling the Christian is enabled to live a holy and separated life in this present world. We have read and are in agreement with the (1) Application, (2) Student Handbook (on line at www.urcap.org), (3) URCA Statement of Cooperation and the (4) Tuition and Financial Information Statement and hereby agree to abide by their stated policies. I further agree to hold the school, church and its agent harmless for any liability to my child or any parent or guardian thereof because of any claims on behalf of my child against the church, school or any agent thereof because of any injury to my child. Should legal action, for any reason, be taken against URCOGIC or URCA or any employee or agent thereof on my child s behalf, and the church, school or its agents not be found at fault, I agree to pay any attorney fees, court fees, damages or other costs that Upper Room COGIC or Upper Room Christian Academy or its agent should incur to defend itself against such action. This Statement of Cooperation will be in effect for as long as my child(ren) listed (or others to be enrolled attend this church school. Student s Name Date Parent or Guardian Signature Date Parent or Guardian Signature Date Administrator s Signature Date

TO BE COMPLETED BY THE PARENTS: UPPER ROOM CHRISTIAN ACADEMY Confidential Teacher Reference Parents, please complete the signature lines below and submit the reference form to a teacher who has taught your child in a core subject (math, reading, language arts, history, or science). For families with multiple applicants, please copy this form to provide one for each applicants teacher. Submit the sealed envelope(s) with your completed application or the teacher may mail it or fax it to the admissions office. I give permission for the following information to be released to Upper Room Christian Academy. I understand that it will be treated confidentially and will not be released to me or anyone else other than the administration of Upper Room Christian Academy. Name of Student: Grade applying for: Signature of Parents: Date: TO BE COMPLETED BY THE PERSON MAKING THE RECOMMENDATION: The student named above is a candidate for admission to URCA. We would appreciate your completing this form within five to seven business days after receiving it from the family. You may return it to the family in a sealed envelope, fax to (919) 829-6193, or mail to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610. Please sign on the reverse side. Thank you. 1. How long have you known the student? How well? 2. In what subject(s)/grade(s) did you teach him/her? 3. Is this student average, above average, or below average in performance? 4. Is the family supportive of the school and the teacher? 5. What are this child s greatest strengths? 6. Does he/she have special academic needs? 7. Do you have any concerns regarding the success of this student? In what ways has this student displayed evidence of good character? PLEASE RATE AS FOLLOWS: E= Exceptional A=Acceptable NS= Needs Support Letter identification Orally identifies beginning sounds Orally identifies words that begin the same Orally identifies words that end the same Orally recognizes rhyme Orally segments words into phonemes (sounds) Orally divides words into syllables Orally substitutes one phoneme for another Looks at pictures and able to tell stories Listens to stories without interruption Speaks in complete sentences using at least five to six words Counts to ten Sort similar objects by color, size and shape Write first name legibly Follows directions KINDERGARTEN CANDIDATE Stays on task Works independently Demonstrates age appropriate gross motor skills Has positive self-image Respects adult authority Responds positively to correction Uses self-discipline Participates willingly FIRST thru FIFTH GRADE CANDIDATE Reads for a variety of purposes, including for information and for leisure Reads and determines meaning of a wide range of text, including poems, stories, speeches, news, reference materials, etc. Understands and explain the effects of addition, subtraction, multiplication, and division on whole numbers and fractions Identifies patterns and makes predictions Writes first and last name legibly Follows directions Stays on task Works independently Has positive self-image Respects adult authority Responds positively to correction Accepts changes and disappointments Uses self-discipline Attendance is consistent Communicates with teacher Communicates and cooperates as a group member Uses reason and logic to resolve conflicts Participates willingly

UPPER ROOM CHRISTIAN ACADEMY Confidential Teacher Reference Continued I recommend this student: ( )Yes ( ) No ( ) With this reservation Referring Teacher Name: (print) Signature School Name Date Position: E-mail Work Phone Please return within one week to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193

UPPER ROOM CHRISTIAN ACADEMY Confidential Pastor s Reference To the Pastor: The student named below is a candidate for admission to URCA. We would appreciate your completing this form and returning it within one week to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or Fax to (919) 829-6193. Name of applicant Candidate for grade To be completed by any full-time Pastor on staff who is well acquainted with applicant: On a scale of 1-10 (10 being the highest), how well do you know the family? Are you currently their pastor or associate pastor? How would you evaluate the parents in the following areas: a. Their church relationship, attendance, and loyalty b. Their personal relationship to Jesus Christ c. Their interest in having their child know and walk with the Lord d. Do they command respect and obedience from their family? 4. To your knowledge, has this applicant accepted Jesus Christ as Savior? 5. How do the parents support their children's spiritual development? 6. What level of involvement does the applicant(s) have in your church? 7. What are the first words that come to mind to describe this applicant? I recommend this student: enthusiastically strongly fairly strongly with reservation Pastor's Signature Date Position: Phone ( ) Church: Address: City: State: Zip To the Parents: I/we hereby authorize the release of requested information to complete the admission process at URCA. I/we understand this is part of my student s application file. Signatures of Parents/Guardians: Date: Please return within one week to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193 Please return within one week to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193

UPPER ROOM CHRISTIAN ACADEMY Student Medical Form Please contact your child s doctor for a copy of the immunization record. If there are additional immunizations required, please schedule an appointment with your pediatrician to have the immunizations completed by September 1. Student Birth Date Parent/Guardian Address City Zip Medical History :(To be completed by parent/guardian) Is your child allergic to anything? Yes No If yes, what? Is your child under a doctor s care? Yes No If yes, why? Has your child ever been hospitalized? Yes No If yes, why? Is your child on any continuous medication? Yes No If yes what? Does your child have any history of disease or recurrent illness? Yes No If yes, what? Immunization Record: The required immunizations are listed below. Please secure a copy of your child s current immunization record from your doctor s office or health professional to submit to the office by September 1. Type of Vaccine DTaP (diphtheria, tetanus and acellular pertussis) Polio Hib (haemophilus influenza type B) Measles Mumps Rubella Hepatitis B Varicella (chickenpox) Number of Required Doses 5 doses* 4 doses 3-4 doses** 2 doses 2 doses 1 dose 3 doses 1 dose*** *The last dose of DTaP must be given after age 4. **Children beyond their 5 th birthday are not required to have any Hib vaccine. ***Vaccination required unless documentation of disease history. In addition to this form, all Kindergarten students accepted to URCA must have a completed copy of the North Carolina Kindergarten Health Assessment Report. (copy included in enrollment packet) The health assessment must be completed by your doctor and returned within 30 days from the start of school. This health assessment should be scheduled prior to the start of the school so that it will remain current for the student s entire Kindergarten academic. The student must have the completed assessment to remain enrolled in Kindergarten beyond the 30 day period. Student s Physician Address Phone Student s Dentist Address Phone Insurance Company Policy Holder Phone Policy Number Group Number Please return within one week to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193

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