APPLICATION FORM FOR NEW STUDENTS

Grade

STUDENT INFORMATION

1. FIRST NAME LAST NAME
2. DOB 3. GENDER F M

4. ADDRESS

5. PHONE # 6. Email:

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7. FAMILY DOCTOR: 8. DOCTORS PHONE #

9. PLACE OF BIRTH

10. DATE OF ENTRY INTO US(MM/DD/YY) (if applicable)

11. S.S #

PARENT INFORMATION

12. MOTHER'S FIRST AND LAST NAME
13. PLACE OF WORK

14. BUSINESS PHONE Cell Phone

15. FATHER’S FIRST AND LAST NAME
16. PLACE OF WORK

17. BUSINESS PHONE Cell Phone

18. Does your child need bus transportation service: (Please check): Yes No


19. Name of person/people you authorize to pick-up child from the school/bus stop:


20. RELATIVES OR FRIENDS PHONE # TO CONTACT IN CASE OF AN EMERGENCY:


21. HOW DID YOU HEAR ABOUT US:
 Friends Newspaper Radio/TV Internet Other

CONSENT FOR EMERGENCY MEDICAL TREATMENT

I do hereby give authority to Big Apple Institute Inc, a/k/a Big Apple Academy staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.

Signature Ok


SCHOOL REGISTRATION CONTRACT

I, residing at agree to register my son/daughter with Big Apple Institute Inc, a/k/a Big Apple Academy and enroll him/her into grade

I undertake to pay $ per month as a tuition fee. Tuition payments are due in full on the First of Each Month (a late payment charge of $50 will be added for payments made after the 5th of each month.) Big Apple Institute Inc, a/k/a Big Apple Academy reserves the right to suspend and/or dismiss a student, thereby refusing to administer services for egregious lack of payments of tuition. Big Apple Institute Inc, a/k/a Big Apple Academy reserves the right to begin these proceeding if tuition payment is submitted beyond the deadline of the 15th of each month.

I understand that this amount covers expenses for attendance of my son/daughter to the Elementary/Junior High School, participation in all school programs, educational instructions, activities. This amount does not include any trips or extracurricular activities outside of school, physicians’ fees, hospital fee s, or medicine other than provided by the standard school emergency procedures.

I also understand that there will be no deductions made for any absences in cases of illness, vacations or other reasons. Full tuition payments are due regardless of school recess, national or religious holidays noted in the School Annual Calendar.

I understand that for the safety, welfare and proper maintenance of all students, Big Apple Institute Inc, a/k/a Big Apple Academy reserves the right, in its sole discretion, to suspend or expel students whose conduct or influence is damaging and/or potentially dangerous to the safety of students, school staff or school property. Big Apple Institute Inc, a/k/a Big Apple Academy reserves the right to determine the severity of the disciplinary issues and threats to the safety of its students, in its sole and absolute discretion. Some egregious examples of misconduct include, but are not limited to; physical violence toward students and school staff, damage or defacing of school property, theft, inappropriate behavior, carrying/use of weapons or materials which may be used as weapons. On the part of the parent, an obvious misrepresentation regarding the medical or mental history of a student will result in action to be taken against the student that may include dismissal from the school. The previously stated examples of misconduct are just examples and Big Apple Institute Inc, a/k/a Big Apple Academy may deem other conduct or misrepresentation as damaging or dangerous, in its sole and absolute discretion. All of the abovementioned disruptions to the safety Big Apple Institute Inc, a/k/a Big Apple Academy may lead to the student’s dismissal from the school. Big Apple Institute Inc, a/k/a Big Apple Academy administrative staff reserves the right to make judgments upon disciplinary action, in its sole and absolute discretion, to be taken against a student (including suspensions or dismissals). In the event of school suspensions or dismissals, no refunds or adjustments will be made to the school tuition fees. In cases of damage done to the school property, the school principal or administrative staff reserves the right to assess the level of damage caused to the school property. All costs for repairs will be charged to the student is account. The school shall have further right to charge and receive collection of attorney’s fees on any unpaid balances plus interest, expenses and court costs, if any, in the event that the school initiates proceedings for the collection on any unpaid balances due.

Big Apple Institute Inc, a/k/a Big Apple Academy assumes no responsibility for the acts done by students when in violation of school rules, local, state or federal laws. Big Apple Institute Inc, a/k/a Big Apple Academy is not responsible for losses of personal property or acts done by students or other persons while off schools premises and the undersigned parents, agree to indemnify and hold harmless Big Apple Institute Inc, a/k/a Big Apple Academy its officers, directors, partners, employees and agents, from and against all claims, actions, damages, liabilities, losses, costs and expenses, including attorney fees, that arise out of or in connection with acts done by students in violation of school, local, state or federal laws.

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the student named above. I also grant to Big Apple Institute Inc, a/k/a Big Apple Academy the right to edit, use and reuse said products, purposes including use in print, on the internet, and all other forms of media. I also hereby release Big Apple Institute Inc, a/k/a Big Apple Academy and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

I hereby confirm that the above named child is in good physical condition and has been examined by a physician within the past 6 (six) months. My child remains in good health and is able to participate in full in all education and sports programs (including swimming) at Big Apple Institute Inc, a/k/a Big Apple Academy.

In cases of extreme emergency, I give permission to the physician or hospital selected by the school officials to hospitalize, secure proper treatment for, order injections, anesthesia, X-rays or surgery to my child. I understand that the cost of medical services will be entirely my responsibility. I understand that Big Apple Institute Inc, a/k/a Big Apple Academy will make every effort to contact me or another designated emergency contact person before or immediately after such emergency treatment is rendered.

Parents/guardians further agree to waive the right to press legal charges against Big Apple Institute Inc, a/k/a Big Apple Academy, its officers, directors, and employees, in those instances where any of the above have not clearly demonstrated negligence leading to injury of your child.

I understand that I have to pick up my child from the school premises at or before 6:00 P.M (this excludes children who are transported via the bus services). I understand that in cases when I am late to pick up my child (after 6:00 P.M ), I am obligated to make an additional payment of $30 for every 30 minutes that my child remains in the waiting room of the school premises. NO EXCEPTIONS will be made.

I have read and understood the Agreement of the Enrollment terms, which have been presented in the Agreement. I agree to all terms contained in the Agreement. In agreeing to the terms presented in the Agreement, I acknowledge that I am also acting on the behalf of the other parent/legal guardian (if that person is not present at the signing of the Agreement) with the authority to enroll my child at Big Apple Institute Inc, a/k/a Big Apple Academy and agree to execute this agreement on his or her behalf. I recognize that Big Apple Institute Inc, a/k/a Big Apple Academy relies upon the representation herein made in accepting my child to Big Apple Institute Inc, a/k/a Big Apple Academy.

Parent’s Signature  Ok

Date

EMERGENCY MEDICAL RELEASE AGREEMENT

As the parent or legal guardian of:

I, , give permission for my child to receive whatever emergency medical care that may be needed to Big Apple Institute Inc, a/k/a Big Apple Academy personnel for the treatment of any injury that may be incurred while in the activity of swimming on premises or elsewhere.

I understand that Big Apple Institute Inc, a/k/a Big Apple Academy will make every effort to contact me or my designated emergency contact before or immediately after such emergency treatment is rendered.

Signature  Ok


LIMITED WAIVER OF LIABILITY

Big Apple Institute Inc, a/k/a Big Apple Academy provides serious education, recreation and sports programs including swimming lessons. Our staff is trained to provide the maximum protection for your child while in our care. Even with all of these safeguards injuries can occur. As a parent or legal guardian of the above named student, I fully understand the risks involved in my child’s participation in all school activities. To the best of my knowledge, my child has no medical conditions which would conflict with his/her participation in Big Apple Institute Inc, a/k/a Big Apple Academy education, sports and recreation programs. I further agree to waive the right to any legal proceedings against Big Apple Institute Inc, a/k/a Big Apple Academy its officers and staff, in those instances where any of the above have not clearly demonstrated negligence leading to injury of the above named student.

Signature  Ok


PARENTS’ REQUEST FOR THE LOAN OF TEXTBOOKS

The school provides free textbooks for its students for the school year. It is expected that every book issued to the student by the school, will be returned in good condition. In the event that a book is missing, damaged, destroyed or simply not returned to the school, the parents of this student will be charged the full cost of the book. It is the responsibility of every student to ensure that each of his/her textbooks is covered with protective covering to ensure its good condition.

It is required by Section 701 of the Education Law that parents submit written requests for the loan of all textbooks. Therefore, all parents are obligated to fill out the request form in order for the New York City Board of Education to provide textbooks in a timely manner to each eligible student.

I (We), parent(s)/ legal guardian(s) of: student of class, at Big Apple Institute Inc, a/k/a Big Apple Academy are requesting the New York City Department of Education to provide my (our) child with textbooks for the 202 - 202 school year.

I (We) promise to take good care of the textbooks and return each of them in good condition at the end of school year. Otherwise, I (we) will be financially responsible for damaged and/or lost textbooks.

Signature  Ok

TRANSPORTATION REQUEST FORM

The undersigned parent(s) or legal guardian(s) of hereby authorize Big Apple Institute Inc, a/k/a Big Apple Academy, (“Organizers”), to facilitate the procurement of bus transportation services for my son/daughter for the school year in their role as facilitators, I/we hereby authorize Organizers to enter into a Pupil Transportation Services Agreement with Academy Transportation Inc. on my/our behalf.

I/we hereby indemnify and hold Organizers faultless from all costs and expenses incurred by them arising from the failure of the undersigned to pay for the bus transportation for the Student(s). I/we hereby release the Organizers and shall hold them faultless for the acts or omissions of Academy Transportation Inc. in the performance of the bus transportation services for Student(s).

PARENT/GUARDIAN INFORMATION:

Parent’s Name:
Address:
CityState Zip Code
Work Phone #
Cell Phone#

STUDENT INFORMATION:

Child’s Name: Grade


SCHOOL BUS TRANSPORTATION LIABILITY WAIVER

As a parent/guardian of the above named child/children, I hereby release Big Apple Institute Inc, a/k/a Big Apple Academy, its agents, employees and trustees from all liability arising out of his/her transportation on the school bus to or from Big Apple Institute Inc, a/k/a Big Apple Academy and throughout all of the extra curriculum activities including daily trips.

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named student. I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold faultless and defend Big Apple Institute Inc, a/k/a Big Apple Academy, its officers, directors and agents, and the chaperones, or epresentatives associated with the event, from any and all actions, claims, demands, damages, costs, expenses and all consequential damage arising from or in connection therewith, and I agree to compensate the school, its officers, directors and agents, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses arising therewith.

I understand that it is my full responsibility as parent/guardian to:

  • Place the child on the bus in the morning, and to meet the child in the evening at the bus stop.
  • Be on time for the evening pickup.
  • Instruct my child/children as to his/her pickup and drop off point.
  • Review with my child/children the School Bus Rules provided by the school.

 Ok

DRESS CODE

Below, you will find clarification on what articles of clothing may and may not be worn to school. This list is being provided to you to clarify whatever confusion you may have in regard to what is considered appropriate clothing. Incorporated into the clothing list is the notice about the kinds of consequences a student should expect if the dress code is to be violated.

1. Footwear must be worn at all times. Unsafe footwear such as: loose sandals, flip flops, shower shoes, wheelie shoes and the like, are not permitted.

2. Hats or other head coverings, except in cases of religious observance, may not be worn in the building.

3. Each student must dress in a manner that does not attract undue attention. Shorts and skirts should not be a distraction. As a general rule, shorts/skirts should not be shorter than the length of your fingertips when your arms are at your sides.

4. Clothing should not be tight, revealing or suggestive. Belly shirts, tube tops, strapless tops, backless sundresses, tank tops, halter tops, off the shoulder blouses, see-through tops, pants that reveal underwear, etc. are not permitted. At no time should a student’s undergarments be visible nor should any skin be visible between the bottom of the student’s shirt and the top of his/her pants/skirt.

5. No clothing may be worn that promotes illegal substances, alcohol or tobacco products. In addition, clothing with messages or graphics deemed offensive, profane, violent, derogatory or otherwise inappropriate is not permitted.

Upon a student’s first violation of the dress code a warning is issued. If the student violates the dress code for the second time, he/she will receive an in-school suspension. Should a student violate the dress code after the second incident, he/she will be removed from school until such time as a meeting can be scheduled with the student, his/her parents and the principal.

Students are expected to comply with the dress code. If a student is sent to the office by a teacher for violating the dress code he/ she is expected to cooperate and not argue or engage in a confrontation with the teacher. Challenging a teacher’s authority will result in greater and more serious consequences.

Signature  Ok

Policies on Wireless Devices and Other Electronics

The following document clarifies Big Apple Institute Inc, a/k/a Big Apple Academy Cell Phone Policy designed to ensure a safe and productive learning environment for our students.

1. Cell phones are prohibited from use in classrooms and any other school areas. Once inside the school, students must store their cell phones/electronic devices in any location that is not visible to teachers, school staff or other students, even though they are turned off.

2. Cell phones and electronic devices may never be turned on during the instructional time or used while any school quiz, test, or examination is being administered.

3. Under no circumstances photographing or video recording is allowed anywhere on the school premises.

4. Use of cell phones or electronic devices for bullying, harassment, or academic dishonesty (including cheating and plagiarism) may result in disciplinary actions or even student expulsion.

5. Students are not allowed to charge their cell phones in school.

6. Students are not allowed to wear Headphones or other Bluetooth enabled devices in class. An exception can be made for Computer class where such devices may be employed for learning purposes.

7. Cell phones must not be used in bathrooms.

8. Cell phones must not be used on school playgrounds and parks.

9. Violation of any cell phone policy stated above will result in confiscation of a device according to the following ladder of disciplinary actions:

  • First Offense: If a cell phone/ electronic device rings, vibrates, or is used for any reason without teacher's permission, or is visible at any time during a school day, a staff member will confiscate the device. The school administration will contact parents, and the confiscated device will remain in the main office until a parent or a guardian picks up the confiscated gadget.
  • Second Offense: The device will be confiscated and remain in the main office until the end of the school year.

10. It should be noted that neither the school nor any of its employees are responsible for loss or damage of any student’s phone whether that device is in the student’s possession or confiscated by the staff. It is the responsibility of the student to adhere to this policy and exercise caution securing his or her belongings at all times.

11. All students can contact their parents during the school day utilizing the specifically designated phone located in the Principal’s office.

Parent signature:  Ok


STUDENT RELEASE FORM

Big Apple Institute Inc, a/k/a Big Apple Academy recommends all participants obtain a physical examination from their physician prior to participating in any or all programs provided by Big Apple Institute Inc, a/k/a Big Apple Academy or its affiliates.

1. The sports programs at Big Apple Institute Inc, a/k/a Big Apple Academy, require the participant to perform a great deal of physical exertion, including sprints, hand-eye coordination activities, and agility drills. This form of exercise directly affects the heart rate, body temperature and respiration, and requires the participant to be in good physical condition. It is up to the participant, or parent/guardian, to ensure that he/she is physically capable and in good physical condition, so as to permit safe participation in the program. Big Apple Institute Inc, a/k/a Big Apple Academy shall have no responsibility, nor liability to confirm the medical condition of a participant. The undersigned recognizes the possible dangers connected with physical activity and competition and it is expressly agreed that participation in the program shall be undertaken at the participant’s own risk. In consideration of the undersigned’s participation in the program, the undersigned hereby certifies and represents that he/she is in good medical condition and is physically capable of safely participating in the program, and utilizing all exercise equipment, athletic equipment, and training required in the program.

2. The undersigned hereby releases Big Apple Institute Inc, a/k/a Big Apple Academy, it’s directors, employees, agents, representatives, coaches, and volunteers, as well as the owners of any facilities in which the program is conducted, on behalf of himself/herself and any one claiming by, through or under the undersigned, from any and all claims of damage, injury, or death, of any kind, arising out of the undersigned’s participation in the program. In addition, the undersigned acknowledges and agrees to indemnify and hold Big Apple Institute Inc, a/k/a Big Apple Academy harmless from any claims of damage, injury or death arising out of the participation of the undersigned in the program, including injuries caused in whole or in part by the undersigned, or another participant.

Moreover, by this release, the undersigned also intends to fully, completely and forever release, discharge, and absolve Big Apple Institute Inc, a/k/a Big Apple Academy all of its directors, employees, agents, representatives, coaches, and volunteers. The undersigned further agrees and promises not to sue or exercise any legal rights to seek damages or relief of any nature from Big Apple Institute Inc, a/k/a Big Apple Academy, its directors, employees, agents, representatives, coaches, and volunteers. The undersigned certifies that he/she has read this release and all of the statements contained herein, and further represents that he/she understood its contents and has voluntarily executed this release. The undersigned understands that he/she is giving up valuable rights and is signing this release voluntarily. The undersigned further agrees that no oral representations, statements, or inducements of any kind apart from this written release have been made with regard to the subject matter of this release.

3. The undersigned hereby warrants that he/she is over the age of eighteen, is competent to contract in his/her name, and that the undersigned has the authority to grant this consent and release.

Signature:  Ok

Relationship to minor:




Parent Authorization
for
4:00 PM and After School Transportation

Date:

I/We

residing at

. New York

the parent(s) of

authorize Big Apple Academy

to receive reimbursement from the Board of Education of the City School District of the City of New York (dba New York City Department Of Education and "NYCDOE") for the transportation of the Student to and from the School for purposes of satisfying the requirements of New York State Education Law Section 3627, i.e., transportation that includes afternoon trips from the School after 4:00 P.M. I/We acknowledge and agree that I/We shall not seek reimbursement for the said transportation independently from the NYCDOE.

Signature:  Ok

When completed, this form should be returned to be retained by child's school.
It is NOT necessary to return this form to the NYC DOE.

OPT Form A4-1




Food Application

INCOME ELIGIBILITY APPLICATION
for Child Day Care Centers

See INSTRUCTIONS on reverse.

DAY CARE CENTER NAME: Big Apple Academy

Print the name of the child(ren) enrolled in Day Care:

1.
2.
3.


DIRECTIONS:

Complete SECTION A if your household:
  1. Receives Temporary Assistance to Needy Families (TANF)
  2. Receives Food Stamps
  3. Participates in the Food Distribution Program on Indian Reservations (FDPIR)
  4. Currently has a foster child enrolled in day care
Complete SECTION B if Section A does not apply:

Sign, date and indicate the Social Security number of the adult signing the certification and return the completed form to the day care center.

SECTION A

TANF Number
Food Stamp Case Number
FDPIR Number
Foster Child's Name
Foster Child's Personal Monthly Income $

An adult household member must sign the application before it can be approved. After reading the following statement and the statement on the back, sign below.

I certify that the above information is true and correct and that all income is reported. I understand this information is being given for the receipt of Federal funds, that officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws

Signature: Ok
Date:

FOR SPONSOR USE ONLY

Sponsor Agreement Number
Total Household Members
Total Income $
Free Reduced Paid
Signature of
Determining Official
Date Determined

SECTION B

List all household members below. Include yourself and all adults and children NOT listed above, even if they do not receive income. Then list all income received last month in your household in the column to the right. Gross income includes: earnings from work, pensions, retirement, Social Security, welfare payments, child support and any other sources of income.

Name of Household Members Monthly Gross Income
1. $
2. $
3. $
4. $
5. $
6. $

An adult household member must sign the application before it can be approved. After reading the following statement and the statement on the back, sign below.

I certify that the above information is true and correct and that all income is reported. I understand this information is being given for the receipt of Federal funds, that officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.

Signature:  Ok
Print Name:
SS# Date:


Section 9
Unless you list the child’s food stamp, FDPIR or TANF case number or are applying for a foster child, Section 9 of the National School Lunch Act requires that you include the social security number of the household member signing the application or indicate that the household member signing the application does not have a social security number. You do not have to list a social security number, but if a social security number is not listed or an indication is not made that the adult household member signing the application does not have a social security number, we cannot approve the application. The social security number may be used to identify the household member in verifying the correctness of the information stated on the application. This may include program reviews, audits and investigations and may include contacting employers to determine income, contacting a food stamp, FDPIR or TANF office to determine current certification for food stamps, FDPIR or TANF benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims or legal actions if incorrect information is reported.

Definition of Income
Income means income before deductions for income taxes, social security taxes, insurance premiums, charitable contributions, and bonds, etc. It includes the following: (1) monetary compensation for services, including wages, salary, commissions or fees; (2) net income from non-farm self-employment; (3) net income from farm self-employment; (4) social security payments; (5) dividends or interest on savings or bonds, income from estates or trusts or net rental income; (6) public assistance or welfare payments; (7) unemployment compensation; (8) government civilian employee or military retirement, or pensions or veteran’s payments; (9) private pensions or annuities; (10) alimony or child support payments; (11) regular contributions from persons not living in the household; (12) net royalties; (13) military benefits received in cash, such as housing allowance; and (14) any other cash income.

Definition of Household
Household means family as defined in Section 226.2. Family means a group of related or non-related individuals who are not residents of an institution or boarding house, but who are living as one economic unit.

INSTRUCTIONS FOR COMPLETING DOH-3688

Instructions for Parents or Guardians:
Write in the name of the day care center in the space provided.
Print the name of each child in your household who attends this day care center.
Section A: If your household receives Temporary Assistance for Needy Families (TANF) or Food Stamps or participates in the Food Distribution Program on Indian Reservations (FDPIR), complete Section A only. Write down the TANF, FS or FDPIR number (do not use your ACD or DSS child care subsidy number) and sign and date the form and return it to the day care center.

Foster children: If your household includes a foster child who is in day care, complete Section A only. Write in the foster child’s name and any income that the child receives from social services for his or her personal use. Write in 0 if the foster child does not receive any income. A separate application must be completed for each foster child. The foster parent or an official who represents the child must sign and date the form and then return it to the day care center

Section B: Write in the names of all the people living in your household, even if they do not have any income. Include yourself and all other adults and children in the household, including unrelated people. Do not include the children in day care, who are listed at the top of the form.

Enter the amount of income each person received last month, before taxes or anything else was taken out. Refer to the Definition of Income and the Definition of Household above. If any amount last month was more or less than the usual, write in that person’s usual income. The signature and social security number of the adult signing the certification is required. If you do not have a social security number, write none.

Instructions for Centers and Sponsors
The For Sponsor Use Only section is to be completed, signed and dated by day care center or sponsor staff.

The sponsor/center representative must review the income eligibility application and ensure that it is completed as indicated in the instructions above. Then indicate the following:

The sponsor agreement number.

Total household members – This item does not have to be completed if the parent completed Section A. Add those indicated in Section B (if completed) to the children enrolled in day care.

Total Income – This item does not need to be completed if the parent completed Section A. Indicate the total monthly income as calculated from Section B. If the parent chooses not to disclose income, the application must be categorized as paid.

Free, Reduced or Paid – Compare the total household income and the total number of household members with the current year’s Income Eligibility Guidelines (CACFP-3687) to determine if the household should be categorized as Free, Reduced or Paid. Use the appropriate column on the CACFP-3687 to categorize their income. For example, if the parent indicated biweekly income, multiply this amount by 26 to determine yearly income.

Incomplete applications (missing signatures, income information, social security numbers, TANF FDPIR or Food Stamp numbers) are categorized in the paid category.

The income eligibility application is valid for one calendar year only.


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