STUDENT APPLICATION PACKET

STUDENT APPLICATION PACKET

Harvest Preparatory School P.O. Box 400 Canal Winchester, OH 43110-0400 Dear Prospective Parent: Welcome! Thank you for your interest in enrolling your child in one of Central Ohio s premier college preparatory institutions. Harvest Preparatory School was founded in 1986 and has been educating children with continued fervor and renewed effort towards providing a quality, distinctive academic experience. In addition to the application, you must also include the following items: $100 Application fee (non-refundable) Must accompany application package $50 for subsequent children of the same family $125 Enrollment fee Must be paid in full before attending any classes at HPS. Current wallet-sized photo of applicant Copy of birth certificate Copy of immunization record Copy of applicant s most recent report card State Achievement Test Scores / Ohio Graduation Test Scores Copy of past IEP, MFE, 504 Plan, etc (if applicable) Copy of high school transcripts (grades 9 12) ODE Child Medical Statement (Pre-school ONLY) Legal court custody papers or relevant guardianship documentation (if applicable) If eligible for the EdChoice voucher program, please contact the Office of Admissions at your earliest convenience for your enrollment schedule. If you have any questions, please contact the Office of Admissions at: (614) 382-1111 ext. 226 (option 3 on automated system) Thank you for your interest in our school. We look forward to working with you and your family during this process and wish your student academic success.

FAMILY PROFILE FORM This form will be retained in your child s file for the duration of his/her attendance at HPS --- PLEASE PRINT / / 20-20 School Year Grade Entering Full Name of Student: Student SS# - - / / Gender: Male / Female City School District: Birth Ethnicity: African-American / Asian/Pacific / Caucasian-American / Hispanic Other: Student s Permanent Address: (street, city, state, zip) Church Affiliation: Name of Pastor: FATHER: Birth Legal Step Grand Guardian Marital Status: Married Single Name: SS# - - Home Address: (street, city, state, zip) Home Phone#: ( ) - Cell Phone#: ( ) - Work Phone#: ( ) - Employer & Occupation: MOTHER: Birth Legal Step Grand Guardian Marital Status: Married Single Name: SS# - - Home Address: (street, city, state, zip) Home Phone#: ( ) - Cell Phone#: ( ) - Work Phone#: ( ) - Employer & Occupation: Referral Source: Family/Friend Church TV Radio Other IMPORTANT Does your child receive special education services: yes no If yes, please specify*: *Paperwork must be submitted at the time of application in order for the student to be accurately admitted. *Failure to submit SPECIAL ED documents may result in dismissal from HPS. Has your child ever been suspended/expelled from school: yes no If yes, please explain: Why do you want your child to attend Harvest Preparatory School?

Harvest Preparatory School Tuition Enrollment Form Student Information New Enrollment Re-Enrollment Last Name First Name Middle Name Grade Entering Parent/Guardian Information Father s Name Home# Work# + Ext Email address Cell# Address Street City State Zip Mother s Name Home# Work# + Ext Email Address Cell # Address Street City State Zip The application fee is $100 ($50 for subsequent family members) and must be paid at the time application is submitted. No application will be considered until application fee is received. The enrollment fee is $125 (must be paid at the time of reenrollment/acceptance) - - Application and Enrollment fees are NON-REFUNDABLE parent initial The Activity Fee is $125 (Pk-5) or $175 (6-12) The SENIOR matriculation fee is $150 - - The Activity Fee and the Senior Fee must be paid in full at enrollment or the parent MUST enroll in FACTS TUITION MANAGEMENT to ensure EFT payment of these fees. Payment Options Parent/Guardian MUST select one of the following methods of payment you plan to use for your student s tuition. Pay in FULL. The full tuition amount must be received prior to the first day of class Monthly payments EFT (FACTS MANAGEMENT TUITION - $38) All payments end in April. You can choose to start making payments on a specific month: June (11 payments) July (10 payments) Aug (9 payments) What day would you like the payments due: 5 th 20 th All applications must have a FACTS TUITION form completed; a one-time fee of $38 will be withdrawn from your account. EdChoice Scholarship Scholarship available to students who are enrolled in select failing Ohio school districts New Applicant (must fill out a Scholarship Request Form) Re-enrolling (must fill out a Scholarship Renewal Form) Transfer (must fill out a Request for Nonpublic School Transfer) I agree to make tuition payments according with the option I ve marked above. I have read the school policy regarding tuition and agree to abide by this policy. Responsible Party s Signature (including EdChoice) 2/2013

Release of All Claims, Insurance Waiver, And Permission to Participate Form Release made this day of 20, by (date) (month) (year) (parent/guardian name) of the city of, county of, state of Ohio as the parents of of the same address. (student name) In consideration of permission granted my son/daughter by World Harvest Church/Harvest Preparatory School to participate in physical education classes along with all extracurricular activities, I hereby release and discharge the Harvest Preparatory School of the city of Canal Winchester, county of Franklin, state of Ohio, its agents, employees and officers from all claims, demands, actions, judgments and executions, administers or assigns, for any personal injuries known or unknown and injuries to property, real or personal, caused by or arising out of participating in the above-stated activities in which my son/daughter may be involved at Harvest Preparatory School. I hereby acknowledge that I have received information regarding the supplemental accident insurance policy that Harvest Preparatory School is offering. I fully understand that it is my responsibility to provide insurance coverage for my child. I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance. IN WITNESS WHEREOF, I have executed release at the city of, Ohio, the day and year first above-written. Father or Legal Guardian s Signature / / Mother or Legal Guardian s Signature / / BOTH PARENTS or LEGAL GUARDIANS (if applicable) MUST sign this form. If not applicable (only one parent/guardian), please indicate N/A (not applicable) in place of signature.

Harvest Preparatory School PO Box 400 Canal Winchester, Ohio 43110 (614)382-1111 Dear Parent/Guardian: This letter is to inform you that Harvest Preparatory School does not provide accident or health insurance coverage for any of our attending students and/or student athletes participating in interscholastic athletics or physical education classes or other school-day activities. It is the responsibility and requirement of the parent/guardian to maintain an active accident and health policy while their children are attending as students of HPS and/or participating in our athletic programs. Harvest Preparatory School is making available information about a supplemental accident insurance policy that parents/guardians may purchase for their students. This insurance policy is being offered by an agency located in Columbus. Harvest Preparatory School has no financial or any other beneficial connection with this insurance company. Our concern if for the health and safety of our students. If you do not have insurance or you are interested in this coverage as supplemental protection, please complete the enclosed enrollment form and mail it directly to the insurance company. If you decide to decline this coverage, please sign and return the enclosed Release of All Claims and Insurance Waiver Form. Thank you for your prompt attention to this extremely important matter. If you have any questions please contact the Admissions office at (614)382-1111. Yours in Christ and Education, HPS Administration

HARVEST PREPARATORY SCHOOL PRE-SCHOOL YEARLY PHYSICAL EXAM VERIFICATION NOTE: This form ONLY needs to be completed for PRE-SCHOOL STUDENTS who ARE NOT entering KINDERGARTEN. This VERIFICATION must be on file at school before the child attends pre-school. Child s Full Name / / Birth Physician Certification: This is to certify that I have examined this child on and have found that he/she: Examined (Mo/Day/Year) (Must be within past 12 months) 1) Has had the immunizations required by Section 3313.671 of the Ohio Revised code for admission to school, or has had the immunizations required by The Ohio Department of Health for infants and toddlers, or is to be exempted from these requirements for medical or religious reasons. See completed immunizations information below. 2) Is free from apparent communicable disease and is in suitable condition to attend a preschool program, based on his/her medical history and physical condition at the time of this examination. Immunization Record (Enter the month/day/year of each immunization and/or attach a current copy.) Vaccines Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Diphtheria, Tetanus, Pertussis (DTAP) Polio (OPV, IPV) MMR, Measles, Mumps, Rubella Haemophilis Influenza Type b (HIB) Hepatitis B Varicella (chicken pox) Physician To Complete and Sign & Below: Name (Please Print): Address: City/State/Zip: Area Code/Phone #: Physician s Signature X (Required) Today s (Required) Parent To Complete: Name of Parent: Address/City/State/Zip: Area Code/Phone #: Name of Dentist: Address/City/State/Zip: Area Code/Phone #: This form is an acceptable form for the Child s Medical Statement used to meet the requirements of rule 3301-37-05A within the Ohio Administrative Code per the Ohio Department of Education Division of Educational Services Early Childhood Educational Section (9/2012). Important: A current copy of ALL immunizations must be provided above or attached.

HARVEST PREPARATORY SCHOOL INHALER/EPI-PEN/INSULIN CONSENT FORM NOTE: This form ONLY needs to be completed and submitted to the school when the student has ASTHMA AND/OR ALLERGIES WHICH REQUIRE AN EPI-PEN OR DIABETES. If applicable, this form must be completed, signed and dated by the PARENT and PHYSICAN and returned to the School Nurse. Purpose: To grant authorization for the possession and use of asthma inhalers, Epi- Pen or insulin during school. Authorization is here by given for Student s Name to receive the medication marked below as indicated. Check any that apply: Asthma Inhaler Epi-Pen Insulin Self-carry Self-administer as permitted by law. Self-carry/self-administer Name of medication: Dosage Procedure to follow in the event medication does not produce the expected relief: Adverse Reactions: Other Special Instructions: *REQUIRED: Physician Name Physician Signature Parent/Guardian Name Parent/Guardian Signature Parent/Guardian Signature Phone# Phone# (work/cell)

EMERGENCY MEDICAL AUTHORIZATION School Year: 20-20 Purpose: To enable parent(s) and guardian(s) to authorize the provision of emergency treatment for students who become ill or injured while under school authority when parents or guardians cannot be reached. NOTE: A signature is required at the bottom of this form. Report any changes to this content immediately to the school registrar. Student s Full Name: Grade: Address: of Birth: / / Street City/State/Zip Custodial/Residential Parent(s) or Guardian(s) (LIVING AT ABOVE ADDRESS WITH THE STUDENT): Full Name Relationship to Student Emergency Phone Numbers Cell# Other# E-Mail: Cell# Other# E-Mail: Emergency Contacts: Allowed to pick up student from school in addition to the parents/guardians listed above. (Note: If a non-residential parent (father or mother) is permitted to pick up the student, provide the name below.) Full Name Relationship to Student Emergency Phone Numbers Cell# Other# Cell# Other# Cell# Other# **IMPORTANT HEALTH DATA**: Please list any and all facts concerning the student s medical history including: 1)Food/Medication allergies, 2)Current medications, inhalers, epi-pens and/or 3)All other chronic conditions (i.e. asthma, diabetes, eczema, seasonal allergies, seizures, sickle cell, physical impairments, etc.) to which a physician should be alerted. 1) Food/Medication Allergies 2) Current Medications/Inhalers/Epi-pen 3) Chronic Health Conditions/Asthma/Other PART I or II MUST BE COMPLETED PART I TO GRANT CONSENT: I hereby give consent for the following medical care providers and local hospital to be called: Family Doctor Phone# Family Dentist Medical Specialist Local Hospital/ Emergency Room Phone# Phone# Phone# In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the student to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity for surgery, are obtained prior to the performance of such surgery. PART II REFUSAL TO CONSENT: 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 the school authorities to take the following action: My signature, in accordance with HIPAA regulations, gives my permission for release of school health information to the school employees and/or other health care providers. X Print Name of Custodial Parent/Guardian Today s Signature of Custodial Parent/Guardian

AUTHORIZATION AND GRANT OF RIGHTS I, the undersigned, hereby grant an authorization to Harvest Preparatory School and its affiliates, agents, licensees, successors, and assigns to use my child s name:, and any photographs, audio or video footage recording during his/her time at HPS. I understand that HPS may broadcast, circulate, publish, reproduce or otherwise use through audio and/or video the subject matters granted by this document unless specific agreement has been made with HARVEST PREPARTATORY SCHOOL TO PROHIBIT SUCH USE. Videos may be sold for HARVEST PREPARATORY SCHOOL, fund raising or WORLD HARVEST CHUCH (an Ohio non-profit organization), services, and afterwards for a period of two (2) years. The rights granted herein are made as a gift to HARVEST PREPARATORY SCHOOL and/or WORLD HARVEST CHURCH. I hereby certify and represent that I have read this AUTHORIZATION AND GRANT OF RIGHTS form and fully understand the meaning and effort thereof and the intent to be legally bound by it. Parent/Guardian Name (print) Student/Child s Name (print) Parent/Guardian Signature / / Please complete the following: Address: City, State, Zip Code: Telephone #

HPS VOLUNTEER SELECTION FORM Parent/Guardian Name: : Home Phone Number: Email: Work Phone Number: Best Time to Contact: Cell Phone Number: Volunteer Availability: Day / Evening HPS Student Name: Grade: HPS Student Name: Grade: HPS Student Name: Grade: HPS Student Name: Grade: HPS Student Name: Grade: Check all that Apply: Partners in Education (P.I.E.) I am interested in assisting in the following areas: Book Fair Library Aide Lunch Room Aide Market Day Helper UPPER SCHOOL SPECIAL EVENTS: Homecoming set-up / clean-up Prom set-up / clean-up ATHLETIC BOOSTERS I am interested in assisting in the following areas: Booster Club Ticket Sales (home games) Concessions (home games) Fund Raising Coordination Special Events set-up / clean-up Volunteer Coordinator (making phone calls) I am committed to partnering with Harvest Preparatory School as a parent and volunteer so that we may offer the students the best opportunities for growth and success. Also, I do understand that for the safety of the students, I will be subject to a background check at the expense of Harvest Preparatory School. Printed Name Signature

Harvest Preparatory School PO Box 400 Canal Winchester, Ohio 43110 (614)382-1111 Parental Acknowledgements: Student Name Grade We the parent(s) of the above named student acknowledge and understand each of the following factors affecting our child s enrollment at Harvest Preparatory School: Parent Initial Failure to comply with all facets of the Student Code of Conduct may result in my son/daughter being placed on Behavior Probation and/or being forced to withdraw from HPS. Poor academic achievement by my son/daughter may result in their placement on Academic Probation. Academic Probation may negatively impact their consideration for renewed application for the next school year. I understand that it is a parental responsibility to ensure that my son/daughter complies with the compulsory attendance laws as established in Ohio law. I understand that excessive absences for unexcused reasons may result in our student being forced to withdraw from HPS. I accept that it is a parental responsibility to immediately notify HPS and provide copies of any/all legal documents that impact the status of the student (ie. Custody documents, restraining orders, probation documents, etc.) I accept and understand the parental responsibility to ensure that my son/daughter has all necessary school uniform items and that they attend school daily wearing only the approved uniform items. I fully understand that it is the role of my son/daughters teacher(s) to determine the academic program they will progress through and that the teacher/administration determines the courseload and the grading requirements to be used in the class. I fully understand that it is the parental responsibility to deliver and pickup my child within the communicated times for the school day. I understand that I may be charged additional fees if I do not pick up my child by the prescribed time. I understand that I must schedule an appointment to meet with my child s teacher(s) to discuss performance issues. I understand that it is not appropriate to drop in to discuss these matters. Parent Signature

HPS Student Code of Honor and Conduct Pledge As a member of the student body of Harvest Preparatory School (HPS), I commit to shaping my conduct and personal behavior in a manner that will honor the vision of the school and adhere to the standards of conduct established by the school. I am voluntarily pledging my commitment to the following Code of Honor: - I PLEDGE to be truthful and respectful to all teachers, staff members, administrators, and school property at all times. - I PLEDGE not to cheat on class work, homework, tests, projects, or exams. - I PLEDGE to follow the rules and regulations in the Student Handbook, as well as those established by my classroom teachers and those printed in the Student Code of Conduct. - I PLEDGE to honor God through respectful participation in all academic and chapel programs. - I PLEDGE not to use profanity, hurtful comments and/or actions, tobacco, alcohol, or drugs while a student of HPS. - I PLEDGE to not engage in sexually promiscuous behavior. - I PLEDGE to be a leader I PLEDGE to encourage all fellow students to fully support this Code of Honor. By my signature below, I state my intent to honor God, my family, and Harvest Preparatory School with my behavior, both on and off campus, for as long as I am enrolled as a student at HPS. I fully understand and accept that any failure to fully honor this code could result in my immediate dismissal from HPS. Print Student Name Student Signature Parent Signature Grade Administrator Witness

HPS Agreement of Understanding Student Enrollment Policy Harvest Preparatory School recruits and admits students of any race, color or ethic origin to all its rights, privileges, programs and activities. In addition, the school will not discriminate on the basis of race, color or ethnic origin in the administration of its educational, athletic, or extracurricular programs. Furthermore, the school is not intended to be an alternative to court-ordered, administrative agency-ordered, or public school district-initiated programs. Discipline Agreement Harvest Preparatory School is partnering with me, the parent, in the training of my children and I believe that discipline is an integral part of that training. Attesting to this belief, I give permission to my child(ren) s teachers and/or Dean of Students, Principal, Assistant Principal or Headmaster of HPS to make and enforce school and classroom rules in a manner consistent with Christian principles as set forth in the Scriptures and in the manner outlined in the Parent/Student Handbook. I agree to follow the Matthew 18 Principle and always go to the person directly involved in the matter in order to work out any problems I may encounter. As the parent/legal guardian, I will work closely with the teachers, Dean of Students, Principal, Assistant Principal and/or Headmaster in the correction and disciplining of my child. Transportation Agreement I authorize Harvest Preparatory School to transport my child(ren) for planned school activities and field trips. I further agree to hold the school and its agents harmless for any liability to my child(ren) because of any claims on behalf of my child(ren) against the school, World Harvest Church, or its agents because of any injury or alleged injury to my child(ren) where negligence is not shown. If legal action should, for any reason, be taken against HPS or its agents or employees on behalf of my child and the school or its agents are not found to be at fault, I agree to pay any attorney fees, court costs, damages, or other costs HPS may incur to defend itself against such action. I am fully aware that this Transportation Agreement shall be in effect for as long as my child(ren) attend(s) Harvest Preparatory School. Financial Agreement The Financial Agreement by the parents is of utmost importance to the financial stability of the school. I, the undersigned note and agree that the duties and obligations of Harvest Preparatory School, as set forth herein, including all those associated with the delivery of educational services and the provision of student records, grades, or transcripts, are contingent on student and parent adherence to all requirements of this agreement including the full payment of all tuition, fees, expenses and other assessments as provided herein or as determined by Harvest Preparatory School. Any breach of this agreement, including the non-payment of tuition, fees, expenses and other assessments as provided herein will entitle Harvest Preparatory School to suspend its performance hereunder and to withhold all student records, grades and transcripts. There are no refunds for student absences. Any tuition account that falls 15 days past due may be subject to late fees. Any tuition account that falls 30 days past due may result in your child being withdrawn from school. I attest that I have read, understand and agree to the contents of this agreement to the best of my knowledge. Father/Male Legal Guardian Signature Mother/Female Legal Guardian Signature Print Student Name / / / / / /

Harvest Preparatory School PO Box 400 Canal Winchester, Ohio 43110 (614) 382-1111 Student Name Grade We, the parent(s) of the above-named student accept and understand that the educational program at HPS is a fee-based, non-public program. We acknowledge that we are responsible for ensuring that HPS receives the appropriate tuition payment. We further acknowledge that HPS will establish an accepted payment schedule and that we are obligated to meet that schedule of payment as agreed upon at the time of enrollment. Failure, at any time, to fully meet the financial obligation of tuition payments, payment fees, payment of lunch accounts, or any other school-related expenses may result in my child s immediate removal from all classes and enrollment in HPS. I acknowledge that I have not been given any promise of special arrangements that would exempt me from this obligation. Parent Signature EdChoice Families: I acknowledge that my child attends HPS as a participant member under the Ohio EdChoice Scholarship Program. As such, I accept full responsibility to ensure that I maintain all eligibility requirements to continue scholarship eligibility. I further agree that I will, upon notification, make immediate arrangements to come personally to Harvest Preparatory School to endorse all EdChoice payments. I acknowledge that failure to immediately respond may result in my child being removed from the school and loss of the EdChoice Scholarship. Parent Signature

CHURCH RECOMMENDATION FORM Mail To: Harvest Preparatory School Admissions P.O. Box 400, Columbus, OH 43110-0400 Phone: (614)382.1111 Fax: (614)837.9591 Parent/Guardian: Please complete this section and forward this form to your church s pastoral leadership, who will then fax or mail the completed form directly to: Harvest Preparatory School- Admissions Student s Name: Grade Applying for: Parent/Guardian Name (print): Parent/Guardian Signature: City School District: Family Address (street, city, state, zip): Administrator: The family above has applied for admission to Harvest Preparatory School. To assist with the selection process, families are asked to secure a reference from a pastoral leader in their church. Please complete this form and return it, at your earliest convenience, to: Harvest Preparatory School Admissions. Thank you. - Are the parents/guardians members of your church? yes / no if so, for how long? - On a scale of 1-10, how well do you know the family? (10 being the highest) - How is the student or family involved in your church s ministry? - How do the parents/guardians support their child s spiritual development? - Does the family tithe to the church? yes / no - Please comment briefly about the student s relationship to his/her family. - Please describe the maturity of the student s spiritual life. - To your knowledge, has the student ever had a serious disciplinary or behavioral infraction? yes / no If yes, please explain. Is there any additional information that you feel would be helpful for us to know regarding this family? Would you recommend this applicant for admission to Harvest Preparatory School? Strongly Recommend Recommend Recommend with Reservation Do Not Recommend Church Leader s Name: Position: Church Name & Address: Signature: : / /

SCHOOL RECOMMENDATION FORM Mail To: Harvest Preparatory School Admissions P.O. Box 400, Columbus, OH 43110-0400 Phone: (614)382.1111 Fax: (614)837.9591 Parent/Guardian: Please complete this section and forward the form to your child s principal, who will then fax or mail the completed form directly to: Harvest Preparatory School- Admissions Student s Name: Grade Applying for: Parent/Guardian Name (print): Parent/Guardian Signature: City School District: Family Address (street, city, state, zip): Administrator: The above student has applied for admission to Harvest Preparatory School (HPS). Please complete this form and return it, at your earliest convenience, to HPS Admissions. Thank you. Please evaluate the student based upon the following categories: Poor Excellent Comments: 1 2 3 4 5 Academic Achievement Academic Diligence Academic Potential Attendance Attitude Conduct Cooperation of Parents Emotional Maturity Family Financial Stability Intellectual Aptitude Leadership Motivation Peer Influence Personal Integrity Teacher Relationship Response to Authority Spiritual Development Has the student been suspended or expelled from your school? yes / no What do you feel is the greatest strength of this student? What do you feel is the greatest weakness of this student? Would you recommend this applicant for admission to Harvest Preparatory School? Strongly Recommend Recommend Recommend with Reservation Do Not Recommend Administrator s Name: Position: School Name & Address: Signature: : / /

School Recommendation Form (pg. 2) **This form must be completed IF the student received Special Education or 504 Plan Services** Student Name Grade City School of Attendance (previously) Student was served based on: IEP 504 Plan The student was served in the following environment(s): Indicate % of time Regular Special Education Resource Room Alternative Services (specify: ) The student s disability is best identified as: SLD ED (behavior) DH Does the student require a Behavior Intervention Plan Yes No Does the student require any assistive technology? Yes No Specify: Student Grade Point Average: GPA OAA / OGT (most recent scores) Grade Reading of current IEP of current MFE Math Science Social Studies Writing