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KLD Learning Center & Academy Grades K -12 Application


The KLD Learning Center welcomes your family to the admissions process. Through this process, we seek to attract highly motivated, achievement-oriented students who will be inspired and challenged by our excellent faculty and award-winning programs. We invite all interested families to visit us so you can discover the exciting array of academic opportunities that we offer each of our students. The KLD Learning Center maintains an open admissions policy and does not discriminate on the basis of race, gender, religion, national origin, or disability in its application process. ----

We are extremely excited and proud of our school and hope you will sense our pride as you learn more about us. Our greatest concern is that we adequately convey to you our culture of love, concern, and mutual respect for one another, and our commitment to instilling Christian values, developing future leaders, and preparing students for life-long learning. Those attributes should avail as you invest the time to visit us and meet our faculty allowing us an opportunity to share our vision and mission with your child, our students, and our community.

Sincerely,

Kevin Deaton President and Founder KLD Youth Foundation, Inc.


Statement
of
Faith
 Dear KLD Students and Parents, The KLD Youth Foundation leadership wishes to be clear in conveying our belief and our heart for God. We depend on the Holy Spirit to lead, rather than on fleshly promotion (Exodus 13:21). Acknowledging that fact, we stand firmly united in our belief in the Father; therefore we expect all those who work for us to participate in the carrying out of the mission of the KLD Youth Foundation. 1.

The Bible is the inspired, only infallible Word of God. ( II Peter 1:18,21)

2.

God eternally exist as the Father, Son and Holy Ghost. (2 Corinthians 13:14)

3.

JESUS CHRIST is the only begotten SON of the FATHER (John3:16), conceived of the HOLY SPIRIT (Matt. 1:20), and born of a virgin. That JESUS CHRIST was crucified, buried, and raised from the dead; that He ascended to heaven and is seated at the right hand of the Father as the intercessor. (Acts 2:23-33)

4.

Salvation comes through Jesus Christ alone, to whom we must respond with repentance, faith, and obedience. Through Christ we come into a right relationship with God, our sins are forgiven, and we receive eternal life. (John 3:16; 16:7-11; Rom.10:13; Eph.2:5,8)

5.

That those who repent and believe should be baptized with water as a symbol of baptism with the Spirit, cleansing from sin, and commitment to Christ. (Acts 2:38; 4:10-12; 8:16; 10:47-48; 19:3-6) That (Matt 3:11; Acts 1:4-8) the true believer receives the Holy Spirit and is baptized into the Body of Christ at conversion, that the Holy Spirit indwells every believer in and is an abiding helper, teacher, giftgiver, and guide. The Holy Spirit, by whose indwelling the believer is enabled to live a holy life, to witness and work for the Lord Jesus Christ which is the standard of living that God has for His people and that it must be sought and activated by faith. (Hebrews 12:14),

6.

God has called us to be and to make disciples of Jesus Christ and to be God's agents of love and reconciliation in the world. Love is more important than the most spectacular gifts, and without love all exercise of spiritual gifts is worthless.

7.

Divine healing through faith in the Lord Jesus Christ, is possible and achievable. Therefore we also minister to those who are broken-hearted and troubled in mind. (Gal 6:1)

8.

God concerns Himself mercifully in the affairs of men. He hears and answers prayer. We believe in the interceding in prayer to Him for all men. (I Tim 2:1-3)

9.

PRAISE and WORSHIP to God is acceptable and worthy of all His believers. (Psalm 149:1)

10. We believe in the personal return of Jesus Christ, in the resurrection of the dead, in God's judgment of all persons with perfect justice and mercy, and in eternal reward and punishment. Ultimately, Christ's kingdom will be victorious over all evil, and the faithful will reign with him in eternal life. (Rev 22:12 – 21)

Student Signature:__________________________________________ Date: ____________ Parent Signature:___________________________________________ Date: ____________

Revised: 10/06/2006 Macintosh HD:Users:jshaffer:Dropbox:Application Packet 09-10:2009-2010 School Packet:Statement of Faith 2010.doc


The KLD Learning Center’s Attendance Policy In order for The KLD Learning Center to maintain high academic standards, the following polices have been set in place to discourage unnecessary absence and tardiness during the school year. The school calendar affords many days of vacation, so parents are encouraged to take their vacations and family trips during scheduled school holidays. All students must maintain regular attendance. This is necessary to successfully complete the daily academic requirement at The Pillar Institute and to conform to the State of Florida attendance laws. Any students who misses more than 10 days in a semester (18 week period), may be asked to repeat the entire semester or be asked to withdraw. If your child is absent due to illness, please call the school office 454-7333 prior to 8:30 A.M. so that this can be noted on your student’s record. The school nurse will also assist parents desiring to obtain assignments for children who are ill. Due to time schedules and teaching load, teachers may be unable to produce assignments for make up work on short notice. Pre-Arranged Absences will be handled through the front office, with written notice only. Emergency absences will be handled on an individual basis. Absences Upon returning to school after an absence, students should report to the front office to get an admittance pass back to class. Work will be made up in the case of excused absences with no grade penalty. Teachers will give make-up tests and help with assignments only when absences are excused. In the case of an absence with a written note, the nurse will give the student pass, which must be presented for admission to all classes missed. The following reasons are considered valid excuses for school absences: 1. Sickness or injury with an approved doctor’s note. 2. Marriage or bereavement in the family. 3. School sponsored trips. 4. Medical appointments, which cannot be scheduled outside of school hours. 5. Absences due to providential hindrances. Two days for every day missed will be allotted to make up missed work from an excused absence. Assignments missed due to unexcused absences will receive a 75%. Tardiness for Elementary Students In the event that a student’s tardiness becomes excessive, the teacher will notify the Elementary Administrator who will set up a conference with the family. Students Check-In Procedure All students who are late will check in the main school office to receive a pass to class.


CONDUCT AND DISCIPLINE The role of discipline at The KLD Learning Center is to create an environment conducive to learning. It is to provide an atmosphere of civility in which due respect will be given to teachers and to individual students, as well as to all institutional and private property so that all members of the community will be allowed to pursue learning without distraction. In addition, discipline at KLD ought always to uphold the essential virtues established in the school’s Mission Statement. KLD recognizes that requiring good conduct in school promotes students’ education on campus, encourages good behavior off campus and helps prepare students for good citizenship in adulthood. Accordingly, students will be expected to adhere to the general rules of the school as well as those rules established by each teacher within his or her classroom.

DISCIPLINARY ACTION Disciplinary action usually proceeds as follows: 1. Reprimand 2. Detention (after school)/ referral 3. In School Suspension 4. Suspension 5. Expulsion To ensure uninterrupted learning, The KLD Learning Center maintains a policy of detentions with parental notification. KLD’s goal is to work closely with parents to uphold standards of courtesy, respect and helpful behavior. Detentions are issued for the following: 1. Improper classroom behavior. 2. Being disrespectful to an adult or child. 3. Inappropriate teasing, roughhousing or fighting. 4. Lying or creating a false impression. 5. Displaying conduct deemed by the teacher or Dean to be unbecoming of a KLD student. A student serves a detention when given by any staff member or teacher. Any student who is subject to a fourth detention during one marking period serves, instead, a one-day Saturday school. Two Saturday schools in one grading period will result in suspension. Suspended students are required to submit all missed academic work at the beginning of the next school day. The Dean may suspend any student when, in his judgment, circumstances necessitate it. Three suspensions in one grading period will result in expulsion. Any student who demonstrates a general unwillingness or inability to abide by classroom or KLD rules is subject to expulsion. After meeting with parents, the student and involved faculty, the Dean will decide if expulsion is warranted.

Class I Infraction: These infractions are minor acts of misbehavior in a classroom, on campus, or at school activities. These acts usually result in a detention or a referral. Such misbehaviors include, but are limited to: chewing gum; food or drink in the classroom; dress code violation; Class disruption; disobedience; disorderly conduct; disrespect toward another student; inappropriate use of cell phone; littering; parking or driving violations; public display of affection; or text messaging during school hours.

Class II Infraction: Class II infraction usually result in an In School Suspension or Suspension and disciplinary probation as determined by the Dean of Students. These infractions are violations of school policy at anytime during

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CONDUCT AND DISCIPLINE 09-10.doc


enrollment and are not limited to school campus or activities. Suspensions should not exceed five (5) days, and disciplinary probation will not exceed one (1) academic semester. In every case of Class II infractions, students will have the opportunity to express their side of the issue and the parents will be contacted. Class II infractions include, but are not limited to: use or possession of alcohol or tobacco products; fighting; destruction of school property or the property of others; inappropriate use of computers on campus; inappropriate internet activities; speeding or careless driving on campus; disrespect; insubordination or direct disobedience to school employees; cheating, plagiarism; stealing; lying to school employees or other adult authority; profanity; inappropriate jokes or language; practical jokes or pranks; obscene gestures; gambling; skipping class or leaving campus without the permission of the school administration; possession of sexually explicit materials; inappropriate touching or remarks of a sexual nature; recklessly endangering or threatening the safety of self or others; repeated or multiple Class I infractions; or willfully accompanying another student who is involved in a Class II infraction.

Class III Infractions: Class III infractions are major offenses, often involving activity that is violation of the law or is a gross act of disrespect toward individuals, school personnel, or property. These infractions are violations of school policy at anytime during enrollment and are not limited to school campus or activities. Class III infractions usually result in dismissal as recommended by the administration and Discipline Committee. Class III infractions include, but are not limited to: committing a Class II infraction while on disciplinary probation; committing a second Class II infraction of the same kind in the same academic year; fornication; sexual misconduct; use or possession of drugs or mood-altering substances*; bringing weapons on campus; distribution of pornographic material; tampering with any fire equipment; vandalism; insubordination to parental, school or civilian authority; repeated or multiple Class II infractions; willfully accompanying another student who is involved with a Class II infraction; and any violation of civil or moral law.

*Drug Testing: If the school administration deems that reasonable cause exists, a student may be required to submit to a drug test after parental notification. Reasonable cause for a drug testing shall exist when school administration, in its sole discretion, determines that reasonable suspicion exists that a student has used or possessed drugs, mood-altering substances, or alcohol and that the results of a drug test would assist in the final determination. The Dean, or his/her appointee, shall make the final decision on behalf of KLD Learning Center as to whether reasonable cause exists. Failure to submit to a drug test may be grounds for expulsion.

Consequences: Detention: A student may be assigned this consequence for minor disruptions in the classroom, on campus, and or any school activities. Students will report to the teacher who assigned the detention. Detentions will be served Monday- Friday after dismissal from 3:30-4:00. Any student who is subject to a fourth detention during a single grading period, serves instead, a Saturday School or a Suspension determined by Dean and Guidance Counselor.

Referrals: A student may receive a referral/detention from any school employee for any Class I infraction. Any student receiving a fourth (4th) referral/detention in a period will be assigned Saturday School. Also any student receiving a fourth (4th) referral/detention in a period will also have a parent conference with the Dean and on the fifth (5th) referral/detention, the student will be assigned a suspension and placed on disciplinary probation.

In School Suspension: In School Suspension is a work-oriented discipline program. The student will be segregated from the rest of the students and will be expected to complete his/her work as given by their instructor. Students will not be allowed to interact with other students during any customary open or free times.

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Suspension: A suspension warns the student and parent that unless a positive and consistent change in behavior is observed, the student may be dismissed or asked to withdraw from The KLD Learning Center. When suspended from school, the student will be placed on disciplinary probation by the Dean. Three (3) suspensions will result in dismissal. Parents of students who receive a suspension are urged to cooperate with KLD in making this correction beneficial to both the student and the school. Students will make up all missed work and receive up to 75% credit when completed in the allotted time according to the Attendance Policy.

Disciplinary Probation: Disciplinary probation is assigned with a suspension. The Dean of Students and the Guidance Counselor assigns probation for a maximum of one (1) semester. Students not making sufficient progress during the probation may be dismissed or asked to withdraw from KLD. Students on academic or disciplinary probation will not be permitted to travel on any school-sponsored trip.

Dismissals: It is our desire that every student succeed at The KLD Learning Center. From time to time, however, the administration will determine, in the best interest of all parties involved, that a student be dismissed or asked to withdraw from KLD due to a poor pattern of behavior or academic choices. A dismissal recommendation will be made by the Dean of Students and the Guidance Counselor. The final approval will be given by the Dean of Students.

Reporting to Authority: Students involved in violations of laws may be reported to the appropriate authorities.

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CONDUCT AND DISCIPLINE 09-10.doc


The future empowered…one life at a time 85 Richland Avenue, Merritt Island, FL 32953 ~ Telephone (321) 454-7333

FAX (321) 454-7335

Fee Schedule Estimated Charges for 2 School Year After school care Academic Learning Lab Dance / End of Year / Prom Fee Late Enrollment Fee New Student Fee Application Fee Books / Supplies / Curriculum Tuition Insurance ID Badges Return Check Fee Speech Therapy - Group Session Base Tuition

$ $ $ $ $ $ $ $ $ $ $ $

5.00 55.00 80.00 125.00 500.00 250.00 310.00 250.00 50.00 30.00 6,495.00

Per day Per session If Scheduled After May 1st

Estimated – Insurance is based on total fees.

May be available through County

The Base tuition of $6,495.00 may increase if additional aid (as stated below)is required. $ 35.00 Per Session Individual Therapy $ 20.00 Per Session Group Educational Therapy

Charges that Vary Uniform Fees Field Trips Finance Charges for Monthly Tuition Summer School Classes

Gym Sets @ $15.00 Polo Shirts @ $15.00 Depends on itinerary Depends on outstanding balance see F.A.C.T.S. outline Varies by class

New students must pay all upfront fees within two weeks of acceptance. Theses fees are non-refundable. All tuition is due prior to school starting unless other arrangements have been made through the Registrar’s office. Tuition insurance may be required for new families and may be waved by the Registrar’s office for returning students. Returning students pay all re-enrollment deposits annually. This non-refundable deposit reserves a student's place for the upcoming school year, subject to the student's satisfactory completion of the current year. Families may choose between three tuition payment plans: one annual payment, two semester payments, or 10 monthly payments. A finance charge of 12% applies to the semester and monthly payment plans. Financing is also available through outside sources; please see Mrs. Deaton for details. Tuition does not include charges for, special events, field trips, and graduations. These fees and similar charges vary by grade level and will be charged where applicable. Student Name: _________________________________________ Amount Due: ____________________________ Parent Acknowledgement by Signature: _____________________________________________________________

Pillar Institute is a branch of the KLD Youth Foundation, Inc. a registered 501(c)3 organization. Macintosh HD:Users:jshaffer:Dropbox:Application Packet 09-10:2009-2010 School Packet:Fee Schedule 2009 2010.doc


Application Fee: _$250.00_ Date Submitted: _________ Check # ________________ School Year Applying for: _______________

Today’s Date

Student Information Student’s Full Legal Name Date of Birth

Γ

Male

Female

Γ

SS#

Resident Address City

Zip

Mailing Address

(if different)

City

Zip

Phone (Home)

Phone (Cell)

Email Address School Presently Attending

Grade:

Please list the names of other siblings that will be attending the Pillar Institute?_____________________ Parent Information Parents: Married Father’s Name

Divorced

Widowed

Separated Occupation

Single

Remarried

SS#: ______________________________________________

Employer Mother’s Name

Work Phone Occupation

SS#: _____________________________________________

Employer

Work Phone

Stepfather’s Name

Stepmother’s Name

Emergency Contact Information What parents have authority to pickup your child? Father Mother

Stepfather

Stepmother

Father’s Cell Phone

Mother’s Cell Phone

Father’s Email

Mother’s Email

Stepfather’s Cell Phone

Stepmother’s Cell Phone

Stepfather’s Email

Stepmother’s Email

Other Contact Name

Home Phone

Work Phone

Cell Phone

Does this person have authority to pickup your child?

Yes

Name

Home Phone

Work Phone

Cell Phone

Does this person have authority to pickup your child?

Yes

Name

Home Phone

Work Phone

Cell Phone

Does this person have authority to pickup your child?

Confidential

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Yes

No

relationship

No

relationship

No

relationship

Last Revised: 3/31/2009


Medical / Health Information Has your child been enrolled in or recommended for any of the following special classes Learning Disability Speech Therapy Physically Handicapped Please explain any above checked items Has your child had any problems with discipline in a previous school?

Yes

No

If yes, please explain Child’s Primary Physician Name: ______________________________________ Phone: ______________ Does your child have any unusual or chronic health issues?

Yes

No

Please list any conditions that may include major surgeries, seizures, asthma, diabetes, etc.

Please list any medication (s) prescribed for the above listed condition (s): We require that parents notify the school of any changes in medication by the following school day.

1._________________________________________ Physician ________________________________ 2._________________________________________ Physician _________________________________

__________________ ___________________________________________________________________________ Please list any mental health diagnosis(es)(Anxiety, Depression, Add/ADHD):

Psycho-social evaluations must accompany this application if the above is filled out. Please see Administrator for further information. As well, please provide a list of medication (s) prescribed for the above listed diagnosis (es).

1._________________________________________ Physician _______________________________ 2._________________________________________ Physician _______________________________ Do you authorize health screening for your student? Please initial your response. Yes ________________ No______________ Do you authorize emergency medical treatment? Please initial your response. Yes ________________ No______________ Are you financially able to meet the monthly tuition requirements?

Yes

No

Comments What do you see as your part in your child’s education?

What is your practicing religion? Is a language other than English used in the home? If yes, indicate language

Agreement I/We certify that the above information is complete and accurate. I/We understand that any information found to be inaccurate may be considered grounds for my/our child’s dismissal from Pillar Institute.

Signature of Father

Date

Signature of Mother

Date

Please note that this form will not be redistributed when our name changes to KLD Learning Center in August 2009.

Confidential

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Last Revised: 3/31/2009


VOLUNTARY INFORMATION SECTION The information requested in this section is not required for admission. Submission of the information is entirely voluntary. Information submitted voluntarily by the applicant will not affect the applicant’s admission to the school. The information, if supplied, will be used for monitoring equal educational opportunity in this school and used for grant information only. In addition, note that applicants with disabilities may voluntarily self-identify for the purpose of requesting reasonable accommodations during the entire application and admission process. Applicants who are English language learners or limited English proficient may voluntarily self-identify for the purpose of receiving interpretive services during the entire application and admission process. Gender:

Female

Male

Race: American Indian or Alaskan Native Asian or Pacific Islander Black White Hispanic Combination of Two or More Races (if checked supply the code from the attached list): Code:________ Person with a disability: Yes If yes, do you need accommodations during the application for admission process? Yes If yes, please describe the accommodations needed. Person who is an English language learner or limited English proficient: Yes If yes, do you need language assistance during the application for admission process? Yes If yes, please describe the assistance needed. NON DISCRIMINATION POLICY The KLD Learning Center a branch of the KLD Youth Foundation Inc admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.

Confidential

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Last Revised: 3/31/2009


Not Hispanic or Latino

Hispanic or Latino

One race White

01

33

Black or African American

02

34

Asian

03

35

American Indian or Alaska Native

04

36

Native Hawaiian or Other Pacific Islander

05

37

White & Black or African American

06

38

White & Asian

07

39

White & American Indian or Alaska Native

08

40

White & Native Hawaiian or Other Pacific Islander

09

41

Black or African American & Asian

10

42

Black or African American & American Indian or Alaska Native

11

43

Black or African American & Native Hawaiian or Other Pacific Islander

12

44

Asian & American Indian or Alaska Native

13

45

Asian & Native Hawaiian or Other Pacific Islander

14

46

American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

15

47

White & Black or African American & Asian

16

48

White & Black or African American & American Indian or Alaska Native

17

49

White & Black or African American & Native Hawaiian or Other Pacific Islander

18

50

White & Asian & American Indian or Alaska Native

19

51

White & Asian & Native Hawaiian or Other Pacific Islander

20

52

White & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

21

53

Black or African American & Asian & Native Hawaiian or Other Pacific Islander

22

54

Black or African American & Asian & American Indian or Alaska Native

23

55

Black or African American & Native Hawaiian or Other Pacific Islander & American Indian or Alaska Native

24

56

Asian & Native Hawaiian or Other Pacific Islander & American Indian or Alaska Native

25

57

26

58

White & Black or African American & American Indian or Alaska Native & Native Hawaiian 27 or Other Pacific Islander

59

White & Asian & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

28

60

White & Black or African American & Asian & Native Hawaiian or Other Pacific Islander

29

61

Black or African American & Asian & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

30

62

31

63

Combination of Two Races

Combination of Three Races

Combination of Four Races White & Black or African American & Asian & American Indian or Alaska Native

Combination of Five Races White & Black or African American & Asian & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

Confidential

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Last Revised: 3/31/2009


STUDENT AGREEMENT STATEMENT

PLEASE READ CAREFULLY and place your initials beside each statement to indicate your agreement.

In making this application, I/We agree that: 1. We will accept the challenge to “train up a child in the way he should go” and state that this training will be carried on in the home. We shall place our trust in Pillar Institute to extend that training more completely. 2. We have read the Parent/Student Handbook and agree to abide by all standards, procedures, and regulations therein. 3. We will pray for the school’s staff. 4. If for any reason our child does not respond favorably to the school’s standards, guidelines, or expectations, which causes us to withdraw him/her we understand that all fees up to and including 30 days from the time of written notification of withdraw are our responsibility. Also, if your child is enrolled for ten or more days in a semester you are responsible for the entire semester’s fees. Tuition is calculated on the basis of the entire year; therefore, no reduction can be made for vacations or school holidays. Tuition is not based upon daily attendance. Should a student transfer before the end of the school year, the parents are responsible for the monthly installments through the current month enrolled. In addition, if a re-enrolled student withdraws after June 1, there is a $250 withdrawal fee. Fees, discounts, and incidental charges are neither prorated nor refundable and cannot be allocated to the accounts of siblings. Also, if any student is on a scholarship withdraws throughout the year they must pay the prorated scholarship amount. 5. We will pay all tuition and fees promptly and according to school policies. Late fees will be added to payments received after the 10 of the month and again after the 20 of the month. When a tuition account is two months in arrears, the student(s) may be withdrawn from school, and records will be withheld until required payments are made in full. th

th

6. If our student is withdrawn, we will notify the school office in writing at least 30 days prior to the planned withdraw date. 7. Our child(ren) will participate on scheduled field trips and other school activities. 8. We understand that PI (Pillar Institute) does not provide voluntary medical insurance coverage for students. Should a student become injured on the premises or during a school sponsored event, the student’s family insurance is the primary carrier. 9. We will promote the spirit of unity within the school by following the Matthew 18 Revised on: 5/10/2010 1:08:00 PMPage 1 of 2


principle. If a problem arises, we will first contact the school personnel who can help (rather than those not involved). We will follow the proper chain of command when necessary until the problem is resolved. The parties to this agreement adhere to Christian principles and believe that the Bible commands them to make every effort to live at peace and to resolve disputes with each other in private or within the Christian community in conformity with the biblical injunctions of I Corinthians 6:1-8, Matthew 5:23-24, and Matthew 18:15-20. Therefore, the parties agree that any claim or disputes arising out of or related to this agreement including, but not limited to, claims arising from statute, ordinance, regulation, case law or any other source shall be settled by biblical based mediation. If resolution of the dispute and reconciliation do not result from such effort, the matter shall then be submitted to an independent and objective arbitrator for binding arbitration. The parties agree that the mediation and arbitration process will be conducted in accordance with the “Rules of Procedure for Christian Conciliation” contained in the Peacemaker Ministries booklet, Guidelines for Christian Conciliation, (http://www.peacemaker.net) which both parties will have had opportunity to review. The parties agree that these methods shall be the sole remedy for any controversy or claim arising out of this agreement and expressly waive their right to file a lawsuit against one another in any civil court for such disputes except to enforce a legally binding arbitration decision. Each party, regardless of the outcome of the matter, agrees to bear one-half of the fees and costs of the arbitrator and any other arbitration expense. The parties to this agreement have had an opportunity to consult legal counsel before signing this agreement. 10. I give permission for my child(ren) to be photographed and/or videotaped. I understand that these may be used on the PI website or in other promotional materials produced for the school or the KLD Youth Foundation; however full names will not be disclosed. 11. Recommendation for admission of the applicant is at the discretion of the PI Administration. Final approval of admission is determined by the PI Admissions Committee. 12. We have carefully read the above guidelines and have accurately completed all items outlined in this application, and we agree to uphold all guidelines as part of the PI family. ___________________________________________________________ Father’s Signature

Date

_________________________________________________________________ Mother’s Signature Date _________________________________________________________________

Student’s Signature

Date

Revised on: 5/10/2010 1:08:00 PMPage 2 of 2


KLD Learning Center Field Trip Permission Slip Periodically, throughout the 2010-2011 school year we will take field trips, this form will be kept in your child file and will be used as the permission slip for the year. I give my permission for ____________________________to go on KLD field trips with KLD Learning Center driven by Parents/Chaperones. I hereby grant authorization to the (KLD Youth Foundation) KLD Learning Center, or its representatives, to provide emergency medical attention to the above said student in the event of a medical emergency while away on KLD field trips. I also hereby agree to hold harmless the (KLD Youth Foundation) KLD Learning Center and its representatives, for any and all actions, damages, or liabilities arising out of the negligent acts of others, in regards to any accident or sickness or treatment thereof incurred by my said KLD student during or from KLD field trips. It is necessary that this form remain on file for every student going on a field trip with (KLD Youth Foundation) KLD Learning Center. No student will be allowed to leave the KLD property without written parental/guardian permission.

Students allergies, if any, are:_______________________________________ Parent/Guardian _________________________________________________ Address _______________________________________________________ Phone _________________________________________________________ Signature ______________________________________________________ (Please bring photo I.D.) STATE OF FLORIDA COUNTY OF BREVARD The foregoing instrument was acknowledged before me this _______day of ____________, ________, by _________________________________. ________________________ Notary Public Personally Known______, OR Produced Identification_______ Type of Identification Produced ___________________________________


2010 – 2011 KLD Learning Center Calendar

Monday Monday Wed. – Fri. Monday Monday Friday Mon.- Fri. Wed. – Fri. Friday Monday Monday Tuesday Monday Tues. – Fri. Monday Mon. – Fri. Mon. – Fri. Friday Friday

August 2 August 9 September 1-3 September 6 September 13 October 15 November 1-5 November 24-26 December 17 December 20 January 3 January 4 January 17 February 1-4 February 21 March 28- April 1 April 4-8 April 22 May 20

Student Days 1st Semester – 89 * This calendar is subject to change…..

Teachers Report Students Report Sign McKay Checks Labor Day/Holiday for All Student Holiday Student Holiday Sign McKay Checks Thanksgiving Holiday End of 1st Semester Winter Vacation Begins Teachers Report Students Report 2nd Semester Begins

MLK Birthday/ Holiday for all Sign McKay Checks Presidents Day/ Student Holiday Spring Vacation Sign McKay Checks Holiday for All End of 2nd Semester Student Days 2nd Semester – 91


May 10, 2010 I ___________________________ understand that I have been invited to attend KLD Learning Center for the 2010-2011 school year. By signing and dating this form I am accepting the invitation to attend KLD Learning Center and want to be counted in the enrollment numbers for next school year. Along with this form I recognized I am responsible for turning in a copy of my birth certificate and social security card to complete my application if I have not already done so. If you have any additional questions please contact the front office (321) 454-7333 during normal business hours.

_____________________________________ Parent of Student

_______________________ Date

_____________________________________ Student

________________________ Date

85 Richland Avenue路 Merritt Island 路 Florida 32953 phone (321) 454-7333 路 fax (321) 454-7335 www.kldkids.org


Student Application Packet