CROSSTYLE ACADEMY

Application
2012-2013

50 S. Wimbrow Drive, Sebastian, FL. 32958

(772)532-6400
CrosstyleKids@aol.com

APPLICATION INSTRUCTIONS
1. Submit all portions of the completed application with the required fees.
Completed application will include these items:
Parent Contract (both parents must sign)
Application Fee - $80.00 (Non-refundable)
Photocopy of grade report and previous years achievement test scores.
2. Health Records must be submitted on the Florida state approved forms. If the student is
enrolled in a Florida school, request that your current school include a photocopy of
health records along with the academic records. If this is the students first school
experience, your pediatrician will have the proper forms.
If the student is coming from out of state, have health records transferred onto
the approved Florida forms by a doctors office or the Florida Health
Department.
The Florida Certificate of Immunization (HRS 680 A or B) must give the day,
month and year.
All students must have a measles booster or MMR #2 recorded on their
Certificate of Immunization (HRS 680 A or B) with the appropriate dates.
The Student Health Examination (HRS 3040) must be dated within one year of
the students first day of attendance at Crosstyle Academy. All students must
have TB screening validated on this form.
Students will not be permitted to begin school until complete health records
have been received and verified by the school office.
3. Birth Certificate with raised seal.

CHECKLIST
_____ Application completed
_____ Both parents have signed the contract
_____ Check attached

_____ Health forms requested

_____ Birth Certificate
_____ Family Covenant

How did you hear about Crosstyle Academy?

___Friend ___ Church ___ Radio ___Flyer ___ Other (explain)___________
__________________________________________________________________

App 2010-2011 Word07192010

Crosstyle Academy

ENROLLMENT APPLICATION
Childs Name ______________________________________________________________________
Last
First
Middle Initial
Date of Birth _____________ Age_________ Sex______ Social Security# ______________________
Address _________________________________City _________________ State_____ Zip________
Home Phone _________________________ Church Name _________________________________
Last School Attended ________________________________________ Grade Completed _________
Address ________________________________ City ______________ State____ Zip_____________
Who has legal custody?_______________________________________________________________

2012-2013
For office Use Only
Grade _______
Teacher __________
Registration
Received
Amount
______________
Check #
______________
Date
_________________

Physician _________________________________________ Phone Number ____________________ Siblings at (CA)

Dentist ___________________________________________ Phone Number ____________________ Yes _______ No

_______

Does the child have physical limitations? (explain)_________________________________________________________________

Allergies? (explain) _________________________________________________________________________________________
Has the student ever been tested for or diagnosed as having a learning disability or attention deficit of any kind? Yes____ No ____
(If Yes, give dates, explanations of the disability and successful treatment received on the reverse side of this page.)

FATHERS INFORMATION
Natural Fathers Name ____________________________________________________ Date of Birth ______________________
Address _____________________________________________ City _____________________ State _________Zip __________
Home Phone _____________ Cell Phone ________________ Work Phone ______________ E-mail _______________________
Place of Employment ______________________________________ Position _________________________________________
Nature of Business ________________________________________ Phone Number ___________________________________
Address ____________________________________ City _____________________ State ___________ Zip _________________

MOTHERS INFORMATION
Natural Mothers Name ____________________________________________________ Date of Birth ______________________
Address _____________________________________________ City _____________________ State _________Zip __________
Home Phone _____________ Cell Phone ________________ Work Phone _____________ E-mail _______________________
Place of Employment ______________________________________ Position _________________________________________
Nature of Business ________________________________________ Phone Number ___________________________________
Address ____________________________________ City _____________________ State ___________ Zip _________________
People to notify in case of an emergency and/or pick up when parent cannot be reached.
1. Name _____________________________________ Phone __________________ Relationship________________________
Address _______________________________ City ____________________ State ___________ Zip __________________
2. Name _____________________________________ Phone __________________ Relationship___________________
Address _______________________________ City ____________________ State ___________ Zip __________________
3. Name _____________________________________ Phone __________________ Relationship________________________
Address _______________________________ City ____________________ State ___________ Zip __________________

Signature of person(s) enrolling student _____________________________________________________ Date____________

CROSSTYLE ACADEMY

Tuition & Fee Schedule

2012-2013
.

Enrollment Information
Kindergarten

1st -8th grades

9th-12th grades

Registration
Non -refundable fee per student

$ 80.00

$ 80.00

$ 80.00

Books

$ 245.00

$ 245.00

$ 285.00

$ 0.00

$ 125.00

$ 150.00

$ 325.00

$ 450.00

$ 515.00

Fees

Standardized Testing (3rd and up)

TOTALS

ABOVE TOTALS DO NOT INCLUDE TUITION

Grade

Full Tuition (Option A)

Due August 24, 2012

10 Month (Option B)
Due 1st of each Month
beginning September 01, 2012

k-4 kindergarten

2,100.00

210.00

1st-8 Grades

$ 2,550.00

$ 255.00

9th 12th Grades

3,000.00

$ 300.00

Tuition paid after the 5th of the month will be assessed a $25.00 late fee.

FINANCIAL INFORMATION
Choice of Billing Plan:
______________ Annual (Option A)
Please refer to fee schedule for due dates.

___________10 Months (option B)

Name of person responsible for paying tuition and other charges, if other than parents.
Name _____________________________________________ Phone ___________________________
Address _________________________________________ City ___________State ____ Zip ________

SCHOOL HISTORY
Is this your childs first school experience? ___Yes ___ No
List all schools previously attended.
Please give the school reference form to the school you are leaving. It is to be completed by a school
official and returned directly to Crosstyle Academy with a photocopy of school records.

School

Full Address & Zip

Grades Attended

Dates

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Has you child, to your knowledge, been involved with:
Alcohol ________

Cheating ___________

Drugs

Stealing ___________

________

Tobacco _______

Sexual Immorality ____

Has your child ever repeated a grade ____Yes ____ No If so, state grade and date. ________________
Has your child ever been tested for or enrolled in a special program?
Gifted

_______

Learning Disabled ________

Special Needs _______

Please give details on a separate sheet.
Reason for withdrawing from present school:________________________________________________
____________________________________________________________________________________
___________________________________

_________________

NAME OF STUDENT

CURRENT GRADE

_________________________
DATE OF BIRTH

Fin Info Word CA 072509

Parent Contract
My signature below and Initials at each () indicates that I have read, understand and agree with the Parent Contract.
In making applications for my child to attend Crosstyle Academy:

I agree to support the standards of the school in every area of its philosophy and policies including academic, behavioral, spiritual, dress, moral,
disciplinary, and maintain the basic principles of Biblical morality in my home.

I agree to assume the responsibility for my childs education by supervising homework, being an encourager, and keeping in regular contact with
my childs teachers.

I agree to support the school to the best of my ability through attendance and participation in the various school activities.
I agree to support to the best of my ability the schools entire program through prayer, time and financial gifts.
NOTE; The school depends upon gifts above and beyond the tuition and thus conducts Annual Fund Raining.
The schools goal is 100% participation by parents.

Further, in the event my child becomes ill or is injured while under school supervision, I give my consent for the school authorities to take the
following steps:
1. Contact a parent of the child and follow his instructions.
2. Contact the childs physician and follow his instructions, in the event neither parent can be reached.
3. Use their own discretion in contacting a properly licensed physician and follow his instructions if the childs physician cannot be reached.

If, in the opinion of a properly licensed and practicing physician, my child needs medical or surgical services which require my consent before being
supplied, and I cannot be reached, I hereby authorize, appoint and empower the Principal, or his/her designee, to furnish on my behalf such
written or oral authorization as may be so required. Further, I release the Principal, or his designee, Crosstyle Academy, and Sebastian Church at
the Cross from any liability which might arise from the giving of such authorization it being my desire that my child be furnished with such
medical or surgical serviced as soon as reasonably possible after the need arises.

I understand that some students appear in school promotional pictures and videos. I do _____ or do not ____ give my permission for my child to
participate if selected.

I understand that this application cannot be considered without the non-refundable application fee.
I understand that once the parent contract has been signed and the enrollment fee paid, I am responsible to pay the full tuition and fees for the academic
year even if I voluntarily withdraw my child or my child is dismissed from the school. Records will not be forwarded to another school until all
financial obligations have been satisfied.

Crosstyle Academy reserves the right to refuse any application, or dismiss any child at any time, for unacceptable work or conduct, or any other
reason it deems necessary. Neither this application nor payment of fees is considered to be binding upon Crosstyle Academy.

If legal action is required to collect tuition, the undersigned will be responsible to pay reasonable attorney fee.

__________________________________________________________________
Fathers Signature

_____________________________________________________________
Date

__________________________________________________________________
Mothers Signature

_____________________________________________________________
Date

__________________________________________________________________
Principals Signature

_____________________________________________________________
Date

***BOTH PARENTS MUST SIGN THIS APPLICATION***

Crosstyle Academy admits students of any race, color, national and ethnic origin to all the rights, privileges, programs and activities made
available to students of the school. It does not discriminate on the basis of race, color, national and ethnic origin in the administration of its
educational policies, admissions policies, financial assistance, or any other school administered program.

Crosstyle Academy 50 S. Wimbrow Drive, Sebastian, FL. 32958 (772)532-6400

CROSSTYLE ACADEMY
REQUEST FOR RECORDS
Student _____________________________________________

Current Grade ____________

This is an official request for the school records of the student named above.

Director of Admission
Crosstyle Academy
50 S. Wimbrow Drive,
Sebastian, FL. 32958
772-532-6400

Please send the following items:

1.

Original health records (HRS form DH 680 A&B and HRS form DH 3040 if
coming from a Florida School).

2. Academic records for the current year.

3. Academic records showing the students final grades from all previous years
available.
4. Test scores from previous achievement tests and diagnostic tests.

Crosstyle Academy 50 S. Wimbrow Drive, Sebastian, FL. 32958 (772) 532-6400

HEALTH HISTORY
Please write Yes or No if your child has any physical concerns and explain

_____ 1.
_____ 2.
_____ 3.
_____ 4.
_____ 5.
_____ 6.
_____ 7.
_____ 8.
_____ 9.

Rheumatic Fever? Any lasting effect?_____________Any limit of physical activity________________

Asthma, Reactive airway disease? List triggers (causes) ______________________________________
Other chronic respiratory problem? If so, what?_____________________________________________
Allergy to insect bites? What insect? _________________________ How serious? ________________
Other Allergies? To what? __________________________________ How serious ?_______________
Diabetes? On insulin? ____________ Time given? ___________Special Diet? ____________________
Heart Disease? _____ Type? ________________ any restrictions on physical activity?______________
Epilepsy, convulsions, fits? Any aura (sensation or feeling)? If so, what? ________________________
Headaches? Frequent? ____________________________ Severe? _____________________________

Please list any medications given daily, and state time to be given.
Medication

Time To Be Given

______________________________________

______________________________________

______________________________________

______________________________________

_____ 10.
_____ 11.
_____ 12.
_____ 13.
_____ 14.
_____ 15.
_____ 16.
_____ 17.
_____ 18.

Eye or vision problems?________________________ Glasses or contact lenses?__________________

Hearing Problems?____________________________ Hearing aids?___________________________
Poor posture, back pain scoliosis, spinal defect? Please explain_________________________________
Sickle Cell, disease? Trait? What are usual symptoms? _____________________________________
Bladder or Kidney disease? Frequent bedwetting? __________________ Frequent infections? _______
Bowel Disease or problems? ____________________________________________________________
taken any medication or poison accidentally? _______________ any effects now? _________________
Any other serious illnesses or accidents? Hospitalized? ________________ when? ________________
Any other medical problems? _________________ If yes, name conditions _______________________
Such as cerebral Palsy, Muscular Dystrophy, ADD, Tourettes Syndrome, Cancer, Emotional
Disorders, Immune Deficiency, Hemophilia, etc.
_____ 19.
Are any special appliances and/or health procedures needed?_________________ If yes, Please explain
________________________________________________________________________________________________
_____ 20.
Can the student participate in the schools regular physical education program? ___________________
Any limits on physical activity?_________________________________________________________
___________________________________________________________________________________
____________________________________________________
Signature of Parent/Guardian
____________________________________________
Emergency phone number of Father

_________________________________
Date
_________________________________________
Emergency phone number of Mother

Request for Rec. Word CA 072509

HEALTH RECORD REQUIREMENTS FOR SCHOOL YEAR

HEALTH
Complete immunization records on Florida HRS form 680 must be received by the school. A
recent physical exam is also required for all kindergarten students and all new students to the
State of Florida. If you are a Florida resident, an original from your doctor is required.
If you are applying from another state, please see the instruction sheet regarding health records.
In order for this application to be processed, the completed Health History Form, with parent
signature must be attached.
Health records have been requested from doctor? Yes_____ No ______
School? ___________________________________________
Name of Students Physician ___________________________________________________
Name

Office Telephone

KINDERGARTEN 6TH GRADE:

1.

HRS Form 3040 Student Health Examination or Statement of good Health

signed by a physician and dated within one year of the first day of school.

2. HRS Form 680 Part A-1 Florida Certificate of Immunization with proof of 2 doses of
measles vaccine, preferably MMR (Measles , Mumps, Rubella)
3. Hepatitis B vaccine series for all students entering kindergarten.

Students transferring from out of state are given 30 days to transfer immunization records
to an HRS Form 680 A Florida Certificate of Immunization. Forms can be obtained at
any physicians office or at any branch of the county Public Health Unit.

Vaccines are available free of charge at your local

Indian River County Public Health Unit.
The telephone number is (772) 770-5401

Health Rec Req Word CA 072509