Deaf Christian Academy

New Student Application

Deaf Christian Academy at Happy Hands
ATTENTION

In order to submit your application you will need:
1. Most recent audiogram
2. Most recent IEP, if applicable
3. Most recent Immunization Record
You will not be able to complete the application without those files or images!

Thank you!

Student Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Social Security Number*
example xxx-xx-xxxx
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Child lives with: *
If other or joint custody, explain:
Grade enrolling to: *
School Year*
School Last Attended*
What church does your family currently attend?*

Parent/Guardian's Information
Parent/Guardian's Name - Primary*

First NameLast Name
Same address as child?*

YesNo
Address *

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Occupation*
Parent/Guardian's Name - Secondary

First NameLast Name
Same address as child?

YesNo
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Occupation
Emergency Contact Information

Please provide at least 2 contacts in case of an emergency.
Contact #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Contact #2*

First NameLast Name
Phone Number*
Please enter a valid phone number.

Student's Hearing Loss Information
Does your child have a hearing loss?*

YesNo
Does your child have a hearing loss on:*

Left EarRight Ear
Left hearing aid/CI make and model
Right hearing aid/CI make and model
Provide most recent audiogram:

Cancelof

Affirmation & Release of Liability
I/We hereby affirm that all of the information contained in this application is true and accurate to the best of my knowledge. I understand that providing any false information would be sufficient reason for the rejection of this application. I further understand that I may be asked for additional written affirmation concerning such items as my child’s medical history and other evaluations, if necessary.

I/We understand that as a Christian school, my child will take part in Bible stories, prayer time and praise songs. Christian values will be taught throughout each day. I realize that Deaf Christian Acadamy at Happy Hands is an extension of me, the parent, and I pledge my support to the Center and staff. I will participate in parent conferences as requested as well as special events to promote my child’s education and to promote the school. I will make every effort to work with the Center personnel to insure the best possible learning experience for my child.

I/We agree to release and save harmless Deaf Christian Acadamy at Happy Hands and its agents, employees and representatives, of and from any and all liability of any kind or nature whatsoever in connection with any loss, accidents, injuries, damage or expenses suffered or incurred by me or my family members as a result of participation in any HHEC, Inc. programs, including any act or failure to act, intentional or unintentional, by any person who is not a representative or employee of HHEC, Inc. or any other volunteer.
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

New Student Application

ATTENTION

Student Information

Parent/Guardian's Information

Emergency Contact Information

Student's Hearing Loss Information

Student's Health History

Medical Contact Information

Affirmation & Release of Liability