MOUNT ZION CHRISTIAN ACADEMY · · 2015-08-07Signed Record Release Form . Mount Zion Christian Academy does not discriminate on the basis of race, sex, or national origin. However,

Mount Zion Christian Academy does not discriminate on the basis of race, sex, or national origin. However, Mount Zion Christian Academy does reserve the right to use appropriate selection criteria in fulfillment of its stated goals and objectives.

Mount Zion Christian Academy

Home of the Mighty Warriors – “Achieving Excellence through Jesus Christ”

3519 Fayetteville Street

Durham, NC 27707

Telephone (919) 688-4245 Ext. 243/244

Fax (919) 688-2201

Apostle Donald Q. Fozard, Sr., Superintendent

Welcome to

Mount Zion Christian Academy

Each new applicant must submit the following documentation:

Full registration fee Completed application forms Copy of recent physical Health Assessment Report (Kindergarten students only)

Copy of immunization record Copy of birth certificate Copy of social security card Copy of current transcript (Grades 9-12) Signed Record Release Form


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MOUNT ZION CHRISTIAN ACADEMY

“Achieving Excellence through Jesus Christ”

3519 Fayetteville Street, Durham, N.C. 27707

(919) 688-4245 ext. 243 or 244 Fax (919) 688-2201

Founder and Superintendent, Apostle Donald Q. Fozard, Sr.

REGISTRATION/APPLICATION FORM

Date ____/____/____ Circle One: New Enrollment Re-Enrollment Grade to Enter_______

Boarding ____ Day School _____ Registration Fees (Non-

Refundable/Non-Transferable): Day School: $150.00 Boarding School: $500.00

Student Information

Name________________________________________________________________________ (Last) (First) (Middle)

Age _____ Sex _____ Date and Place of Birth ________________________________

Social Security Number ______ - ______ - ______ Home Phone ( ) _______ - ________

Address (City) (State) (Zip)

The last grade successfully completed

Grades have been: _____ Above Average _____ Average ______ Below Average

Has student failed any grades? _____ Yes _____ No If yes, what grade(s)?

Last school attended:

Has the child ever been expelled, dismissed, suspended or refused admission to another school?

If yes, please explain.


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Has the child ever been in trouble with the law, arrested, etc.? If yes, please explain.

Does the child have any physical handicaps? If yes, please explain.

Please give any additional information that might be helpful to the teacher(s), (family situations,

discipline problems, etc.).

Please give reason for selecting this school.

School recommended by:

Church now attending:

Pastor’s name _____________________________ Phone ( ) _______ - ________


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Parent Information

Father’s Name

Employer __________________________________ Email

Work Phone ___________________________ Cell Phone

Address (If different)

Mother’s Name

Employer __________________________________ Email

Work Phone ___________________________ Cell Phone


Student lives with: _____ Parents _____ Mother _____ Father ______ Guardian

Guardian’s Name:


Employer ____________________________________

Work Phone _________________________ E-mail

Statement of Cooperation

I have completed all the sections of this registration form to the best of my ability, and believe the

statements are accurate. I will support the policies and procedures of Mount Zion Christian

Academy if my child is accepted. I also understand that all tuition payments and all fees are

non-refundable.

___________________________________ ______/______/______ Parent/Guardian Signature Date


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Special Transportation Agreement

In order for your child(ren) to be transported off campus for field trips, sporting events

etc., we need your permission. Please sign the following release.

I agree to let my child(ren) be transported to and from off campus school activities by

authorized school or church staff members. I release Mount Zion Christian Academy and Mount

Zion Christian Church from liability for injury to my child(ren) during such trips. This agreement

will remain legitimate as long as my child(ren) are enrolled at Mount Zion Christian Academy.

___________________________________ ______/______/______ Parent/Guardian Signature Date

Authorized Pick-Up List

Student Health/Emergency Medical Information

Please note that this information will stay on file as long as your child attends MZCA. Therefore,

we need parents to keep this information up-to-date.

Name of Student(s) ________________________________ Date _____/_____/_____

___________________________________

___________________________________

List the names and phone numbers of two responsible adults we can contact in the event that an

emergency occurs and we are not able to reach you.

1. Name

Home Phone Work Phone

2. Name

Home Phone Work Phone

Name of child’s physician Phone

Dentist preferred Phone


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Does the child have health insurance? _____ Yes _____ No

If yes, please give name of insurance company

Hospital preferred:

Does your child have any allergies?

Is your child on any medications?

Does your child have any health problems which would exempt him/her from physical education,

vigorous exercise, or walking long distances? _____ Yes _____ No If yes, please describe

below.

If your child’s health changes, it is your responsibility to notify us in writing and by

telephone. In the event of an accident or illness, I hereby grant permission to the authorized staff

and representatives to administer necessary first aid and/or to take my child, by car or

ambulance, to a medical facility for additional treatment. I give permission to a doctor or nurse to

administer the necessary medical attention in case of an emergency. I give permission for my

child to be admitted to the hospital if necessary. I hereby release Mount Zion Christian Academy

and Mount Zion Christian Church from any liability.

_____/_____/_____ Parent/Guardian Signature Date


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Code of Conduct

A pledge of conduct is required from all Mount Zion Christian Academy students. This

pledge is not designed to usurp parental authority or influence, but to set some behavioral

standards which reflect Christian principles—both during and after school hours. Please consider

this pledge seriously; it is an important part of the application. The pledge must be signed by

parents and students each year upon re-enrollment.

Specific guidelines and standards have been established for students at Mt. Zion

Christian Academy. The students are taught moral and ethical principles based upon the Word of

God. Standards are established to help shape students’ behavior.

Please read carefully and sign the following Student and Parent Pledges. Details

concerning the behavior standards and dress code standards are found in the school handbook.

All new students will be required to submit to a random drug test.

Student Pledge

As a student at Mount Zion Christian Academy, I agree to uphold the school’s standards

of behavior and maintain Christian standards of honesty, courtesy, morality, and respect for

authority. At school or away, I will not smoke, use narcotics, drink alcoholic beverages, nor

abuse other similar substances. I will not steal, cheat, swear, or use indecent language. I will not

bring weapons, dangerous objects, or firearms to school. I will dress and act in a decent and

respectful manner at all times. I will not have a rebellious spirit or a continued negative and

uncooperative attitude. I realize that my failure to uphold these standards may be grounds for

expulsion. Additionally, I agree to support the decisions and policies of the teachers and school

administration. I will strive to speak positively about my school at all times. (Parents of younger

children, please read and discuss with your child(ren).

____/_____/_____ Student’s Signature Date

Parent Pledge

I agree with the above Code of Conduct and will require consistent behavior from my

child in accordance with these standards.

____/_____/_____ Parent/Guardian Signature Date


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Statement of Faith

A. The Scriptures. The Bible is the inspired Word of God, the product of Holy Men of old who spoke and

wrote as they were moved by the Holy Spirit. The New Covenant, as recorded in the New Testament,

we accept as an infallible guide in matters pertaining to conduct and doctrine. (II Timothy 3:16;

I Thessalonians 2:13; II Peter 1:21).

B. The Godhead. Our God is one but manifested in three persons – The Father, the Son, and the Holy

Spirit (Philippians 2:6 and Matthew 3:16-17). God the Father is greater than all; the Source of the Word

(Logos) and the Begetter (John 14:28; John 16:28; John 1:14). Jesus is the Son of God, One with the

Father, the Word flesh-covered, the One Begotten, and has existed with the Father from the beginning

(John 1:1; John 1:18; John 10:30). The Holy Spirit proceeds from both the Father and the Son and is

eternal (John 15:26).

C. Man, His Fall and Redemption. Man is a created being, made in Likeness and image of God, but

through Adam’s transgression and fall, sin came into the world. “All have sinned and come short of the

glory of God.” “As it is written, there is none righteous, no not one.” Jesus Christ, the Son of God, was

manifested to undo the work of the devil and gave His life and shed His blood to redeem and restore

man back to God (Romans 5:12; Romans 3:9-10; I John 3:8; Galatians 3:13-14). Salvation is the gift of

God to man, separated from works and the law, and is made operative by grace through faith in Jesus

Christ, producing works acceptable to God (Ephesians 2:8).

I have read the Statement of Faith of Mount Zion Christian Academy and am in agreement with its doctrine

and principles.

____/_____/_____ Parent/Guardian Signature Date

____/_____/_____ Student Signature Date


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Photo Release Waiver Authorization and Release

I hereby grant permission to Mount Zion Christian Academy, and its officers, trustees, employees, agents, students, representatives, successors, licensees and assigns (hereinafter "the Academy") to photograph my image, likeness, or depiction and/or that of my minor children (if applicable). I hereby grant permission to the Academy to edit, crop, or retouch such photographs, and waive any right to inspect the final photographs. I hereby consent to and permit photographs of me and/or those of my minor children to be used by the Academy worldwide for any purpose, including educational and advertisement purposes, and in any medium, including print and electronic. I understand that the Academy may use such photographs with or without associating names thereto. I further waive any claim for compensation of any kind for the Academy’s use or publication of photographs of me and/or those of my minor children (if applicable). I hereby fully and forever discharge and release the Academy from any claim for damages of any kind (including, but not limited to, invasion of privacy; defamation; false light or misappropriation of name, likeness or image) arising out of the use or publication of photographs of me and/or those of my minor children (if applicable) by the Academy, and covenant and agree not to sue or otherwise initiate legal proceedings against the Academy for such use or publication on my own behalf or on behalf of my minor children. All grants of permission and consent, and all covenants, agreements and understandings contained herein are irrevocable. I acknowledge and represent that I am over the age of 18, have read this entire document, that I understand its terms and provisions, and that I have signed it knowingly and voluntarily on behalf f myself and/or my minor children (if applicable). Signature Print Name Date Print Name of Minor Child Print Name of Minor Child Print Name of Minor Child Print Name of Minor Child Print Name of Minor Child


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Mount Zion Christian Academy Home of the Mighty Warriors – “Achieving Excellence through Jesus Christ”

Records Release Form

3519 Fayetteville Street Durham, North Carolina 27707

Telephone (919) 688-4245 Ext. 242 Fax (919) 688-2201

(Name and Address of Previous School)

(Name of Pupil) (Grade) (Age) (Date of Birth)

Send records to: Mount Zion Christian Academy 3519 Fayetteville Street Durham, North Carolina 27707

Birth Certificate

Immunization Records

Transcript (Cumulative Folder)

Achievement Test Scores (SAT/ACT/PSAT)

Discipline Records

Other (IEP, 504, etc.)

Parent/Guardian Signature

Documents

MOUNT ZION CHRISTIAN ACADEMY · · 2015-08-07Signed Record Release Form . Mount Zion Christian Academy does not discriminate on the basis of race, sex, or national origin. However,