APPLICATION“CREATED TO MAKE A DIFFERENCE” The following forms need to be completed in full at the time of enrollment. ❏ Ambassador Information Card ❏ Interview and Testing form (1st – 12th-grade ambassadors only) ❏ Background Information form ❏ Personal Appearance Agreement ❏ Statement of Parent/Guardian ❏ Volunteer form ❏ Immunization form ❏ Request for Ambassador Records form (On lines after “TO,” please fill in the ambassador's previous school name/address; please fill out the rest of the form as indicated. Please fill out a separate form for each ambassador.) ❏ $25.00 non-refundable application fee per child (waived) Ambassador Information Card 2022-2023 Ambassador's Full Name * First Name Last Name Ambassador's Date of Birth * MM DD YYYY Nickname Grade * Residence Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Ambassador lives with * Home Phone * (###) ### #### Parent/Guardian Contact #1 Name * First Name Last Name Relationship to Ambassador * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Parent/Guardian #2 Name * First Name Last Name Relationship to Ambassador * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Ambassador may also be released to Name * First Name Last Name Phone * (###) ### #### Relationship to Ambassador * Ambassador may NOT be released to Full Name First Name Last Name Full Name First Name Last Name Personal Appearance Agreement As a Christian institution, the necessity of a dress standard is important and vital due to the face, whether we like it or not, we are judged and evaluated by appearance. Our attire should reflect a wholesomeness that is reflective of our Christian testimony. While styles vary from year to year, making it difficult to state absolutes in dress code, our goals remain the same: clean, neat and modest. We urge parents to be certain that their ambassador is appropriately and neatly dressed when leaving for school. It is ultimately the parent’s responsibility to make sure the ambassador follows the Personal Appearance Guidelines in the ambassador handbook. We urge ambassadors to be cooperative and maintain good attitudes as they follow the Embassy Innovation Academy Personal Appearance Guidelines. Parent/Guardian Signature * Date * MM DD YYYY Ambassador Signature * Date MM DD YYYY Statement of Parent/Guardian In signing this application, I (we) agree to the following: ● I have read the ambassador handbook and am willing to have my children educated in accordance with it. ● The school has full discretion in the grade placement of my child. ● The school reserves the right to dismiss any ambassador who does not cooperate with the educational process. ● I understand that tuition rates do not cover the cost of operating the school, and thus my participation is needed in lending practical help and prayer support in a mutual effort to train our children through Fair Share and other volunteer opportunities. ● I have read the Financial Policy and agree to pay all tuition fees and other financial obligations to Embassy Innovation Academy on or before the due date, without a reminder, and in accordance with these policies. Parent/Guardian Signature * Date MM DD YYYY Ambassador Background Information Name First Name Last Name Indicate any other las name used Address Of School last attended * Address 1 Address 2 City State/Province Zip/Postal Code Country Name of School last attended * Has the Ambassador ever been dismissed, suspended, or disciplined for disruptive behavior? If Yes, please explain Does the Ambassador have any diagnosed or suspecting learning disabilities or special educational requirements? If Yes, please explain Has the Ambassador ever skipped or repeated a grade? If Yes, please explain Is there any court order in effect limiting the presence of or removal of this Ambassador by any persons or person during school hours? If Yes, please explain Has the ambassador attended a Christian school in the past? If Yes, Please list School name and dates of enrollment How did you hear about Embassy Innovation Academy? * If you were referred, by who? Does your family attend church regularly? * If Yes, what is the name of your Church Ambassador Health Information Has your child been diagnosed with any learning disabilities such as dyslexia, ADHD, etc., that require special treatment and/or programs? * If Yes, please explain Does your child have any health problems (including any concerns or physical limitation that would affect P.E. or recess)? * If Yes, please explain Is your child regularly taking any medications? * If Yes, please explain Does your child have a bee sting allergy? * If Yes, please explain Does your child have a food allergy? * If Yes, please explain Does your child have any other allergies? * If Yes, please explain Doctor/Physician Information First Name Last Name Phone (###) ### #### Doctor/Physician Location Release Information I hereby give my consent for (child’s full name) to receive emergency medical treatment as may be considered necessary in the opinion of the attending physician(s) or paramedic(s) during the school year. * Please Type in Childs Full name Parent/Guardian Signature * Throughout the year, ambassador photos and names are collected for the yearbook, used in school advertising and released to the media including social media for honor roll, awards, special events, etc. If you wish for your child to not be photographed it must be sent to our office in writing each year. Parent/Guardian Signature * Date * MM DD YYYY Embassy Innovation Academy Volunteer Opportunities Helping make Embassy Innovation Academy a great place to learn! Ambassador Name First Name Last Name Grade Parent Name First Name Last Name Phone (###) ### #### Email Opportunities to Serve Yearbook Chairperson Yearbook Committee Booster Club Fundraiser Committee Newsletter Supplies Donation Coordinator Public Relations/ Community Service/ Advertising Director Substitute Teacher (Volunteer) Friday Place Base Chaperon Maintenance and building projects Any skills or training not mentioned that may be of use to the school Director of an extracurricular activity of your choosing Use this box to specify your choice or to serve in a area not listed The following document's are needed to complete your child's school file 1. Completed Admission Application 2. Signed and dated Enrollment Contract 3. Copy of Birth Certificate and Social Security Card 4. Copy of current immunizations 5. Copy of transcript from last school including any standardized testing and/or individual education plans 6. Completed Contact Information including who may and may not pick up your child 7. Signed and dated Authorization for Emergency Medical Attention 8. Signed and dated Over-the-Counter I (name of Parent/Guardian) have read the Embassy Innovation Academy 2022-2023 handbook and have gone over this handbook with my child (child's name) and will adhere to the Embassy Innovation Academy handbook. * Parent/Guardian Signature Date MM DD YYYY Billing Plan * Choose one 10 month (Aug-May) Tuition Information Admission Process To enroll your child into EIA, you must complete and turn in the application form 2022-2023. Thank you!
