St. Andrew welcomes your family to ours. When you come by to meet with us,

please be prepared to tell us a little more about yourself, your child, and what brings you to us.

The Teaching Ministry Of

St. Andrew Missionary Baptist Church

Private School Parent Coop Prayer Clinic APPLICATION Family Information

Student’s Name________________________________________________________________________________

                                                Last                                                                        First                                        Middle

Applying for grade:___________________ Date of Birth:_______________________________________________

 

Name by which student prefers to be called:__________________________________________________________

Home Address:_________________________________________________________________________________                                                Street                                                                                      Apt. #

                                                City                                                                                        Zip Code

Father’s Name:_________________________________________________________________________________

Home Address:_________________________________________________________________________________

                                                (If different from above)                                                   Phone Number(s)

Occupation:_________________________________ __________________________________________________

   Business Phone

Business Address:______________________________________________________________________________

Mother’s Name:________________________________________________________________________________

Home Address:_________________________________________________________________________________

                                                (If different from above)                                                   Phone Number(s)

Occupation:________________________________  __________________________________________________

                                                                                                                                Business Phone

Business Address:______________________________________________________________________________

Names & Ages of brothers and sisters:______________________________________________________________

_____________________________________________________________________________________________

 

Candidate’s general health: (Please describe any special conditions of which the school should be aware)

_____________________________________________________________________________________________

_____________________________________________________________________________________________EDUCATIONAL BACKGROUND

Current School with dates of attendance_____________________________________________________________

Address of School______________________________________________________________________________

                                                Street                                                      City                                                        Zip

Presently enrolled in grade:__________________________REFERENCES

List the names and positions of two current school references, one of whom should be the present English teacher:

Name:________________________________________________________________________________________

                                Teacher                                 Grade                                                                     Subject

Name:________________________________________________________________________________________

                                Teacher                                 Grade                                                                     Subject

List the name, address and phone of an adult (other than a relative) who knows the candidate well, from whom the Saint Andrew Missionary Baptist Church Academy & Theological University Parent Corporation, may request a recommendation:____________________________________________________________________________________________________________________________________________________________________________

 

Date of Application:__________________________________________________

Signature of Parent/Guardian:_____________________________________________________________________

Signature of Candidate___________________________________________________________________________

 

HOW DID YOU LEARN OF THIS SCHOOL?_____________________________________________________ The Teaching Ministry of theSt. Andrew Missionary Baptist ChurchPrivate School Parent Coop Prayer ClinicIDENTIFICATION AND EMERGENCY INFORMATION

To be completed by Parent or Guardian
Child’s Name: LAST                                     MIDDLE                      FIRST                  Sex Telephone

(      )
Address          Number                  Street                Apt #       City                    State           Zip

  Birthdate
Father’s Name: LAST                           MIDDLE                    FIRST Business Telephone

(      )
Home Address   Number           Street           Apt #        City                State        Zip Home Telephone

(      )
Mother’s Name: LAST                          MIDDLE                   FIRST Business Telephone

(       )
Home Address    Number          Street             Apt #       City               State        Zip Home Telephone

(      )
Person responsible for child:  LAST NAME              MIDDLE           FIRST Business Telephone ------------

Home Telephone----------------

ADDITIONAL PERSONS WHO MAY BE CALLED IN EMERGENCY
NAME ADDRESS TELEPHONE RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN EMERGENCYPhysician                                               Address                            Medical Plan & Number                          Telephone

                                                                                                                                                                                (       )----------------------------------------------------------------------------------------------------------------------------------------------------------

Dentist                                                   Address                            Medical Plan & Number                          Telephone

                                                                                                                                                                                (        )-------------

If physician cannot be reached, what action should be taken?

v  Call Emergency Hospital                          

v  Other   (Explain):________________________________________________________________________

Names of persons authorized to take child from the facility

(child will not be allowed to leave with any person without written authorization from parent/guardian)
NAME RELATIONSHIP
   
Time child will be called for:  
Signature of Parent or Guardian  TO BE COMPLETED BY FACILITY DIRECTOR / ADMINISTRATOR

Date of Admission:                                                                                 Date Left:

CONSENT FOR  MEDICAL TREATMENTAs the parent, agency representative or legal guardian, I hereby give consent to

 

______________________________________________ to provide all emergency dental or

                                    Facility Name


medical care prescribed by a duly licensed physician (M.D.) or Dentist (D .D.S.) for

 

____________________________________________

                                     Name

This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.

 

Child:_______________________________________ has the following medication allergies: 

 

____________________________________________________________________________
 

_______________________                                         _________________________________

            Date                                                                          Parent signature

 

______________________________________________________________________________

            Home Address

 

______________________________________________________________________________

            Home Telephone                                                         Work Telephone

(       )                                                                           (      )                          

                        

The Teaching Ministry of the

St. Andrew Missionary Baptist Church

Private School Coop Prayer Clinic

Annual Health Inventory

 

Dear Parents/Guardians:

Your child’s health is significant in planning his/her school program. It is important that he/she is feeling at his/her best in order to benefit from school each day. Occasionally, children have health conditions that affect their routine  performance at school. It will help us to assist your child if we are aware of his/her unique needs. Please take a moment to complete this form and return it to the Administrative Office.

 School:____________________________ Teacher:_________________________  Grade:__________

 

Child’s Name:______________________________________    Age:_____    Birthdate:____________

 

Parent/Guardian’s Name:___________________ Relationship:______________   Phone:__________

 

Emergency Contact Person:__________________ Relationship:______________  Phone:__________

 

Please complete the Health Inventory below by filling in the appropriate boxes.1. When did your child have his/her last visit to the doctor for a physical exam?   

   __Within last year

   __Between 1 & 2 years ago

   __Over 2 years ago

   __ Never

 

2. What was the reason for the last visit?

   __A checkup

   __Illness/injury                     If illness/injury, please explain:

 

3. Does your child have a regular doctor?

    __yes                                    If “yes”, please give name:

   ___no                                                                                                                                                     

 

4. When did your child have his/her last visit to the dentist for a dental checkup?

 __Within the last year

 __Between 1 & 2 years ago

 __Over 2 years ago

 __Never

 

5. What was the reason for the last visit?

__ A checkup

__ Toothache/injury                                           If illness/injury, please explain:

 

6. Does your child have a regular dentist?

  __Yes                                                   If “yes”, please give name:

  __No

 

7. Has your child ever had a serious accident?

  __Yes                                                   If “yes”, please explain:

  __No

 

8. Has your child ever had an operation?

 __Yes                            If “yes”, please explain:

 __No9. Does your child use:      hearing aid                       dental braces/retainers              crutches

    __eyeglasses                       __walker/braces     __other:______________

 

10. Does your child have difficulties with?

     __ speech                                                        If yes please explain:

     __hearing

     __vision

     __attention

 

11. Is your child’s physical activity limited?

     __Yes

     __No                                           If yes, is there a doctor’s statement on file with the school?

                                                                                            Yes             No

 

12. Has your child had any of the following?   Please check:

      __Allergies (please list) ______________________________

      __Asthma              __Heart Condition            __Tuberculosis           __Other lung diseases

      __Diabetes            __ Seizures                        __Hemophilia             __Sickle Cell Anemia

      __Ear Infections   __Rheumatic Fever            __Fever over 103        __Juvenile Rheumatoid                                                                                                                                                                      Arthritis

__Upsets easily/Temper Tantrums                 Frequent colds or flu (more than three a year)

__Frequent headaches (more than one per week)                        __Other__________________

  13. Does your child currently take medication prescribed by a doctor?

       __ Yes                                                             If yes, please write the name of the prescription:

       __ No

 

14. Does your child need to bring any medication to school?

      __ Yes                                                              If yes, please write the name of the prescription:

      __ No

 

15. Does your child have a condition that could be a school emergency?

      __ Yes                                                            If yes, please explain:

      __No

                        16. Is there any additional information that your think is important for the school to know?

     __ Yes                                                                  If yes, please explain:

     __ No

 

17. I would like to speak with the school office                            __Yes                     __No

The best time to reach me is:                                            Parent Signature:

My telephone number is:

THANK YOU VERY MUCH!

 
The Teaching Ministry Of

St. Andrew Private School Parent Coop Prayer Clinic

Theological & Academic University 

Record Release Form


To:…………………………………………………………………………………………………..

            School currently/previously attended by student

I hereby give my permission for the release of any records of my daughter/son:
 

……………………………………………………………………………………………………

Student’s Name 

Requested by the St. Andrew Private School
Please forward this request to the following address:

St. Andrew Missionary Baptist Church
PRIVATE SCHOOL PARENT COOP PRAYER CLINIC
THEOLOGICAL & ACADEMIC UNIVERSITY

2608 West Street
OAKLAND, CA 94612
ATTN: Administrative Office

For further information, you may contact the school at (510) 465-8023

Fax to:  (510) 465-0725


                                                ____________________________________________________

                                                Parent Signature & Date

                                               ____________________________________________________                                                              

                                                Address
**Any fields that do not apply to you mark N/A*

We encourage you to bring the following:

• INFORMATION ABOUT YOUR CHILD'S ACADEMIC HISTORY
• RECORDS FROM THE MOST RECENT SCHOOL YOUR CHILD ATTENDED
• INFORMATION ABOUT YOUR EXPERIENCE WITH PUBLIC SCHOOL/PRIVATE
• INFORMATION ABOUT THE NEIGHBORHOOD WHERE YOU RESIDE
• INFORMATION ABOUT THE FAMILY'S FINANCIAL STATUS/GOALS/NEEDS
• INFORMATION ABOUT ANY SPECIAL NEEDS YOUR CHILD HAS
• ANY INFORMATION YOU FEEL WILL GIVE US INSIGHT INTO YOUR CHILD