“a school with a heart, in the please attach a current ... · agapÉ boarding school 2 previous...

AGAPÉBOARDINGSCHOOL

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ADMISSIONAPPLICATION(Pleasecompleteentireapplication)

Pleasetypeorprintclearly: Personcompletingapplication?__________________________________

Date:__________________________________HowdidyouhearaboutAgape?__________________________________

ApplicantInformation IsapplicantaU.S.citizen?___________________________________

Nameofchild:_____________________________________________ S.S.#:_______-_____-________ Age:___________

Birthplace:__________________________________________ Birthdate:____/_____/______ CurrentGrade:_______

Ethnicity:____________________________________________ ReligiousAffiliation:_________________________________

Isyourchildpresentlylivingathome?Y/NIfno,pleaseexplain:_____________________________________

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Haircolor:_____________________Eyecolor:____________________Height:__________Weight:___________

Tattoos:___________________________________________Scars:____________________________________________________

Pleaselistfriendsorrelativesthatyourchildmighttrytocontact:(includephonenumbers)

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PLEASEATTACHACURRENTPICTUREOFYOURTEEN

HERE

“A school with a heart, in the heart of Missouri”


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PreviousPrograms Hasyourchildhadpreviousplacementsoutsidethehome?Y/N

Ifyes,pleaselistallotherprograms,schools,familymembers,andhospitalorotherinstitutions:

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ParentInformation(Ifdeceasedpleasenotedateandcause)

Father’sName:_____________________________________ Age:__________Occupation:___________________________

Address:________________________________________City:________________________State:_________Zip:___________

HomePhone:_____________________________WorkPhone:____________________________Fax:___________________

Cell:__________________________________________ Email:_________________________________________________________

Bestmethodofcontact:________________________________________ Besttimetocontact:________________

Mother’sName:__________________________________________Age:_____Occupation:__________________________



Cell:__________________________________________ Email:_________________________________________________________


Stepfather’sName:_______________________________________Age:_____Occupation:________________________

Address:_______________________________________City:________________________State:_________Zip:___________


Cell:__________________________________________ Email:_________________________________________________________


Stepmother’sName:__________________________________Age:_________Occupation:________________________



Cell:__________________________________________ Email:_________________________________________________________



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Pleasegivethefollowinginformationofeachimmediatememberofyourfamily:

NAME AGE RELATION CURRENTLYLIVINGWITH

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Personstonotifyincaseofemergency(otherthanparents)

Name:_________________________________Relationship:________________________Phone:______________________

Name:_________________________________Relationship:________________________Phone:______________________

SocialHistory:Pleasedescribethepersonalityofyourchildinthefollowingphases)

Birthtosixyearsold:________________________________________________________________________________________

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Seventotwelve:______________________________________________________________________________________________

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Thirteentopresent:__________________________________________________________________________________________

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PresentProblems

Whatareyourchild’scurrentbehaviorproblems?_______________________________________________________

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FamilyRelationships(pleasedescribeyourchild’srelationshipwithfamilymembers)

Father:_________________________________________________________________________________________________________

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Mother:________________________________________________________________________________________________________

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Stepfather:____________________________________________________________________________________________________

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Stepmother:___________________________________________________________________________________________________

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Siblings:_______________________________________________________________________________________________________

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Pleasedescribeanyothersignificantrelationshipswithfamilymembers:_____________________________

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Divorce/SeparationHistory

Areparent’sdivorced?Y/NIfyes,when?______________Whohascustody?_________________________

Hasthedivorceorseparationbeenanissueforyourchild??Y/NIfyes,explain:___________________

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Anypastorcurrentcustodybattles?Y/NIfyes,explain:_______________________________________________

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Haveeitherparentremarried?Y/N Hasthisbeenanissuewithyourchild?Y/N

Ifyes,pleaseexplain:________________________________________________________________________________________

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Adoption

Wasyourchildadopted?Y/N Ifyes,when?____________________________________Age?______________

Wherewasyourchildadoptedfrom?___________________________ Previousadoptionhomes?Y/N

Pleaseexplainanyspecialcircumstancesleadinguptotheadoption:__________________________________

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Hastheadoptionbeenanissueforyourchild?Y/NIfyes,explain:___________________________________

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Dotheyknowinformationabouttheirbiologicalparents?Y/NIfyes,explain:_______________________

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Havethebiologicalparentsbeeninvolved?Y/NIfyes,explain:________________________________________

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BehavioralHistory

Hasyourchildeverdemonstratedaggressiveorviolentbehavior?Y/NIfyes,pleaseexplain:

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Hasyourchildhadanyinvolvementwiththelegalsystem?Y/NIfyes,pleaseexplain:

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Hasyourchildevertalkedabout,threatened,orattemptedsuicide?Y/NIfyes,pleaseexplain:

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Doesyourchildhaveahistoryofself-mutilation?Y/NIfyes,explain:________________________________

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Hasyourchildhadanychangesinbehaviorormood?Y/NIfyes,explain:___________________________

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Whendidthesechangesoccur?_____________________________________________________________________________

Hasyourchilddiscussedanyabnormalthoughts?Y/NIfyes,explain:________________________________

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Pleasedescribethehistoryofanyspecificdisorderyourchildhashad:________________________________

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Pleasecheckanyofthefollowingcharacteristicsthatapplytoyourchild:

❑ Shyortimid ❑ Withdrawn ❑ Daredevilbehavior❑ Bed-wetting ❑ Crueltoanimals ❑ Playwithfire❑ Unhappy ❑ Fearoflosingcontrol ❑ Verbalabuse❑ Witnesstoviolence/abuse ❑ Strangethoughts ❑ Difficulttocontrol❑ Aggressivetowardsothers ❑ Loner ❑ Destructive❑ Restless ❑ Ganginvolvement ❑ Physicalabuse


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Ifyourchildhaseverrunaway,pleaseanswerthefollowingquestions:

Howmanytimeshasyourchildranaway:__________ When?______________ Alone?Y/N

Howlongwashegone?_____________________Didhecallhome?Y/NDistancetraveled?____________

Whodidhestaywith?_____________________________ Wasyourchildinvolvedinillegalactivity?Y/N

Ifyes,pleasedescribeindetail:_____________________________________________________________________________

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Whatwasthereasonyourchildranaway?________________________________________________________________

SocialRelationships

Doesyourchildmakefriendseasilyorhavedifficultymakingfriends?_________________________________

Doesyourchildprefertobealone?Y/N Doesyourchildgetalongwellwithothers?Y/N

Areyourchild’sfriendsusuallyyounger,older,orthesameage?_______________________________________

Areyourchild’sfriendsusuallythesamesexoroppositesex?___________________________________________

Hasyourchildrecentlychangedfriendgroupsorstoppedhangingoutwithcurrentfriends?Y/N

Whattypeofpeergroupsdoesyourchildspendtimewith?_____________________________________________

Whatareyourfeelingsaboutyourchild’sfriends?________________________________________________________

SexualHistory

Toyourknowledge,hasyourchildbeensexuallyactive?________________________________________________

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Hasyourchildhadanysexualproblems?__________________________________________________________________

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Hasyourchildexhibitedanysexualidentityissuesorinappropriatesexualbehavior?_______________

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Toyourknowledge,hasyourchildeverbeensexuallyabusedorraped?_______________________________


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Historyofabuse:(Sexual,Physical,andEmotional)

SpecificHistoryofAbuse

SpecifyWhetherVictimorOffender:_______________________________________________________________________

Incest:_________________________________________________________________________________________________________

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Rape:__________________________________________________________________________________________________________

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Molestation:__________________________________________________________________________________________________

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SexualPerpetration:_________________________________________________________________________________________

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PhysicalAbuse:_______________________________________________________________________________________________

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Verbal/EmotionalAbuse:____________________________________________________________________________________

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Neglect:_______________________________________________________________________________________________________

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Legalmeasurestaken:_______________________________________________________________________________________

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Child’sbehaviorandattitudeexhibited:____________________________________________________________________

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Degreeoffamilyinvolvement:______________________________________________________________________________

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MedicalInformation

Pleaselistallwhohaveexaminedortreatedyourchild:(Physicians,Psychiatrist,Psychologist,etc.)

Name:___________________________________________ NatureofServices:__________________________________

Address:________________________________________________________Date(mm/yy):_____________Age:________

Medications:______________________________________________________________________Currentlytaking?Y/N

DoctorPrescribing:______________________ReasonforPrescribing:________________________________________

Reasonfordiscontinuing/side-effects:_____________________________________________________________________

Ifyouansweredyestoanyoftheabove,pleaseexplain:_________________________________________________

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Pleaselistanyotherdiagnosedmedicalconditionandthedateofdiagnosis:_________________________

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Pleaselistanyallergies:_____________________________________________________________________________________

Pastorrecenttobacco,alcoholordruguse?Y/NPleaseexplain:______________________________________

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Familyhistoryofsubstanceabuse:_________________________________________________________________________

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Pleasecheckanyofthefollowingconditionsthatapplytoyourchild:

❑ Childhooddiseases ❑ Headache ❑ Seizures❑ Sinus ❑ Thyroid ❑ Pneumonia❑ Asthma ❑ Emphysema ❑ Tuberculosis❑ Heartattack ❑ Enlargedheart ❑ Valvedisease❑ HeartMurmur ❑ Highbloodpressure ❑ Emotionalproblems❑ Chestpain ❑ Gallbladderproblems ❑ Hepatitis❑ Heartburn ❑ Ulcers ❑ BowelDisease❑ Hemorrhoids ❑ Bloodystools ❑ Kidneystones❑ Bladderproblems ❑ Brokenbones ❑ Arthritis❑ Anemia ❑ Cancer ❑ Diabetes


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Toadequatelyunderstandtheparent/childrelationshipanditsimpactonthechild,itisveryimportantthatweknowofanyfamilytherapy.Pleaselistallpsychiatric,psychologicaland/ormarriageandfamilytherapythatthefamilymembershaveparticipatedin:NameofTherapist:______________________________________________ Datesseen:___________________________

Address:___________________________________________________ NatureofServices:__________________________

Whatwasaddressed:________________________________________________________________________________________

Frequency:__________________Familymemberswhoparticipated:_______________________________________

NameofTherapist:______________________________________________ Datesseen:___________________________




NameofTherapist:______________________________________________ Datesseen:___________________________




Pleaselistanypast/presentmedicalconcernsorconditionsoffamilymemberswhichmayaffect

yourchildorfamilyrelationships:__________________________________________________________________________

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AdditionalInformation

Havetherebeenanycircumstancesinthechild’slifewhichhavebeenhardforhimtoaccept?

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Havetherebeenanydeathsoffamilyorfriendsthathavegreatlyimpactedyourchild?

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Whatdoesyourchildbelievehiscurrentproblemtobe?

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WhatareyourexpectationsofplacementatAgapéBoardingSchool?

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Whatdoyouseeasyourchild’sestimatedstayatAgapéBoardingSchool?

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Howdoyouplantobeinvolvedwithyourchild’sgrowthwhileatAgapéBoardingSchool?

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Whatisyourchild’sperceptionofbeingplacedatAgapéBoardingSchool?

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Whatdoyouseeyourchild’sandyourfamily’sgoalofsendinghimtoAgapéBoardingSchool?

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Pleaseattachanyadditionalinformationthatyouthinkwillbehelpfulinunderstandingyourchild’scurrentsituation.


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Whatareyourchild’sspecialneedsandstrengthsinthefollowingareas?

Physical

Needs:_________________________________________________________________________________________________________

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Strengths:_____________________________________________________________________________________________________

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Familial

Needs:_________________________________________________________________________________________________________

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Strengths:_____________________________________________________________________________________________________

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Educational

Needs:_________________________________________________________________________________________________________

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Strengths:_____________________________________________________________________________________________________

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Spiritual

Needs:_________________________________________________________________________________________________________

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Strengths:_____________________________________________________________________________________________________

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Social

Needs:_________________________________________________________________________________________________________

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Strengths:_____________________________________________________________________________________________________

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Psychological

Needs:_________________________________________________________________________________________________________

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Strengths:_____________________________________________________________________________________________________

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EducationalHistory

Pleasedescribeyourchild’sperformance(grades,relationshipwithteachers,behavior,etc.):

Elementaryschool:___________________________________________________________________________________________

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JuniorHigh:___________________________________________________________________________________________________

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HighSchool:__________________________________________________________________________________________________

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Hasyourchildhaddifficultiesinschool?Y/N Ifyes,pleaseexplain:________________________________

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HasyourchildhadanIEP(IndividualizedEducationPlan)orspecialeducationplacement?Y/N

Ifyes,pleaseexplain:________________________________________________________________________________________


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HasyourchildbeendiagnosedwithADD,ADHD,ODDorotherdiagnosis?Y/NIfyes,pleaselist:

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Doesyourchildhavepooreyesight,hearingloss,speechimpediment,etc?Y/NIfyes,please

explain:_______________________________________________________________________________________________________

Hasyourchildeverrepeatedgrades?Y/N Ifyes,whichgrades?________________________________

Hasyourchildeverbeensuspendedorexpelled?Y/N Ifyes,when?_________________________

Pleaseexplain:________________________________________________________________________________________________

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NameofSchoolsAttended Grade Year ReasonforLeaving

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Nameofcurrentschool:_______________________________________________ Phone:________________________

Address:______________________________________City:________________________State:_______Zip:______________

CurrentGrade:____________ StillAttending?Y/N Lastgradecompleted:_______________

Whatdoyouperceiveasyourchild’scurrentacademicneeds?__________________________________________

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Youarenowreadytosubmityourapplication!Youcansubmityourapplicationbyfax,email,ormail.

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AgapéBoardingSchool12998E.1400Rd.●Stockton,MO65785Office:417-276-7215●Fax:417-276-7217

Email:[email protected]


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MedicalDisclosureAgapéBoardingSchoolisaprivateChristianboardingschoolanddoesnotacceptanyfederalorstatefunds.Assuch,weareexemptfromhavingtoaccommodateanystudentregardlessofdisabilityandwillonlyacceptstudentsthatwecan,inourdiscretion,safelyandappropriatelyhouse,carefor,andministertowhileconsideringourlegitimateandvitalinterestinprotectingthehealthandsafetyofthestudentsandemployeesatAgapé.Therefore,itisthepolicyofAgapéBoardingSchooltonotadmitstudentswithcommunicablediseasesrequiringongoingmedicalorotherspecialsupport,andwewillconsideronacase-by-casebasisanycurrentorpotentialstudentswithmedicalconditionsordisabilitiesrequiringongoingmedicalorotherspecialsupport.

FinancialInformationEffectiveAugust1,2018

Agapé Boarding School strives to deliver the best possible training, both spiritually andeducationally, at the most reasonable price possible. Tuition and fees are geared to cover theregularoperationalexpensesoftheprogram.WeurgeparentsandotherstoconsiderthatAgapéBoardingSchool,asaministryofAgapeBaptistChurch,isexemptfromfederalincometaxundersection501C (3A)of the InternalRevenueCode as anorganizationdescribed in section501C(3A); therefore, any donated cash and/or property may be deducted from the donor’s federalincometax.Tuitionis$3,250permonth,foratotalof$39,000forayear.Tuitionincludesroomandboard.Inaddition,parentsareresponsibleforenrollmentfeesof$2,750whichmustbepaidonthedateofthestudent’sarrival.

Totalamountdueonstudent’sarrivalTuition:$3,250.00

EnrollmentFees:$2,000.00

Uniformandstartupitems:$750.00

*Student Account: $150.00

TotalDue:$6,150.00---($6000.00-Non-refundable)

Subsequentmonthly tuition payments of $3,250 are due as determinedby the enrollment dateandconfirmedbythefinanceofficeatenrollment.Pleaseplanforyourpaymenttoarrivenolaterthantheduedateasthereisno“graceperiod.”Onceanaccountbecomes30dayspastdue,aletterwill be sent to the parent or guardian tomake the account current. If the account is notmadecurrentwithin15daysofthatletter,thestudentwillbedischargedandsenthomeattheparent’sexpense.If a parent withdraws a student before the contract is up or if the student is withdrawn forfinancial reasons as listed above, there will be a $3,500 early termination fee added to thestudent’sbill.IfAgapéexpelsastudentfornon-financialreasonsthenthisfeedoesnotapply.

“a school with a heart, in the please attach a current ... · agapÉ boarding school 2 previous...

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