2013-2014 _______Registration Application_______

John Milledge Academy, 197 Log Cabin Rd. N.E., Milledgeville, GA 31061 www.johnmilledge.org

1. $75 Nonrefundable Registration Fee must accompany applications ($125 if paid after April 13) 2. Nonrefundable Technology & Book Fees are payable at registration - $120 Pre Kindergarten - 12th Grade 3. If a student properly withdraws before the first day of school, the student will be refunded all but one months tuition. 4. Final acceptance of new students is based on entrance test results and/or examination of test scores from previous year (grades 1 - 12). 5. JMA does not have a program for special needs students and can only make minor accommodations in its academic program (see Educational Support letter, Parent/Student Handbook). 6. JMA does have a random drug testing program. All students in grades 7-12 are subject to testing. 7. JMA reserves the right to use any picture, audio, or video of students in promotional material including the internet. 8. The use of social media by individuals in and outside of John Milledge Academy is widespread and will continue to be prevalent in todays society. Social media can be a very powerful, positive and productive way of communication. However, improper and inappropriate use of social media can be very damaging, carry legal implications, and/or be considered an infringement of third party rights. Consistent with our existing policies, John Milledge Academy reserves the right to dismiss any student, parent and/or other family members that choose to do harm to the institution and/or its constituents through the misuse of social media.

I have read and agree to the above statements. ___________________________

Student Information Student

Last Name First Name

Date ____________________________

Middle Name

Preferred

Birth date

Gender

Student email address

Grade Applying for

Family Information Father

Title Address
Email

Last Name City

Employer

First Name State Zip

Middle Name Home Phone ( Cell Phone (

Work Phone (

) ) )

(check all that apply) Financially Responsible _____ Lives With ____ Send Mail? ____ JMA Graduate (year)? _____

Mother
Title Last Name First Name State Zip Middle Name Home Phone ( Cell Phone (
Work Phone (

Address (if different than above) City

Email Employer

) ) )

(check all that apply) Financially Responsible _____ Lives With ____ Send Mail? ____ JMA Graduate (year)? _____

Other
Title Last Name First Name State Zip Middle Name Home Phone ( Cell Phone (
Work Phone (

Address (if different than above) City

Email Employer

) ) )

(check all that apply) Financially Responsible _____ Lives With ____ Send Mail? ____ JMA Graduate (year)? _____

Do we have your permission to administer simple medications such as Non-Aspirin Pain Relievers/Fever Reducers without calling the parents? (Please Circle) Yes No List any known medical conditions or allergies and be specific. ___________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Application is made on behalf of the student by the undersigned subject to the conditions and changes that may occur as determined by the Board of Trustees to be in the best interest of the Academy and those in attendance. The Head of School and Trustees reserve the right to dismiss at any time any student, who in their opinion does not meet the scholastic achievements established by the Academy, has become a disciplinary problem, or will not abide by the rules and regulations set by the Academy. It is the responsibility of the student and the parent(s) to be aware of school policy and procedures as outlined in the Student Handbook which is considered a continuation of this contract. Upon dismissal the student will forfeit all fees and tuition. ____________________ Date of Application Application approved/rejected by: ________________________________________ Parent/Guardian Signature _____________________________________ Chairman of Admissions Committee 2 __________ Date

Pick up in case of Emergency

For students in grades Pre-K 6, list the names and phone numbers of anyone not listed above that may pick up your child or that we may call in case of emergency.

Name

Phone number

Pickup

Emergency Contact

For New Students Only

Name & address of school last attended _____________________________________________________ Has this student qualified for any Special Education Programs? Yes _______ No _______ Has this student been allowed to withdraw in lieu of suspension or expulsion? Yes _______ No _______ If yes, explain __________________________________________________________________________ Has this student ever been denied admission to a school? Yes _______ No _______ If yes, explain __________________________________________________________________________

Grandparent Information

Grandmother __________________________________________ Work phone _____________________ Grandfather ___________________________________________ Work phone _____________________ Home Phone __________________________________ Cell Phone ______________________________ Mailing address ________________________________________________________________________ ________________________________________________________________________

Grandparent Information

Grandmother __________________________________________ Work phone _____________________ Grandfather ___________________________________________ Work phone _____________________ Home Phone __________________________________ Cell Phone ______________________________ Mailing address ________________________________________________________________________ ________________________________________________________________________ 3