Kankakee Trinity Academy
410 S. Small Ave.
Kankakee, IL 60901

Application for Admission

Date child will enter: _________________________________Grade child will enter: ______
                                                (month)          (year)

NOTE: ALL OF THE CONFIDENTIAL INFORMATION REQUESTED IS NEEDED IN ORDER THAT THE UTMOST HELP MAY BE GIVEN TO YOUR CHILD.

Pupil: _____________________________________Date of Birth ___________Sex _____
         (Last Name)   (First Name)   (Middle Name)
Birthplace: ________________________________Home Telephone (____)____________
Local Address: ____________________________________________________________
Student living with: ___Father ___Mother ___Both ___Guardian ___Other (Please List)
Parents:       Parent/Guardian #1                                             Parent/Guardian #2
Name: ______________________________   Name:_______________________________
Role: ____Father _____Mother _____Step        Role: ____Father ____Mother ____Step
Mailings : Mr./Mrs. ____________________    Mailings: Mr./Mrs. _____________________
Address: ____________________________    Address: _____________________________
              ____________________________                  _____________________________
Phone #: (____)______________________    Phone #: (____)________________________
Pager/Cel.# : (____)__________________      Pager/Cel.#: (____)_____________________
Marital Status: ____Married ____Separated          Marital Status: ____Married ____Separated
                     _____Divorced ___Remarried                               ____Divorced____Remarried
          ______Single _____Widow/Widower                             ___Single ____Widow/Widower
Highest Level of Education: ______________    Highest Level of Education: _____________
Church Affiliation: ______________________    Church Affiliation: _____________________
Pastor: ______________________________    Pastor: _____________________________
Attend Church: __Regular __Often __Seldom       Attend Church: __Regular __Often __Seldom
Occupation: __________________________    Occupation: __________________________
Employer: ____________________________    Employer: ___________________________
Business Address: _____________________       Business Address: __________________
                           _________________                               _______________________
Business Telephone: (___)_______________       Business Telephone: (____)______________
Business Telephone #2: (___)____________     Business Telephone #2: (___)___________
Work Hours: _____________________                Work Hours: _______________________
Social Security #: ______________________       Social Security #: ________________________

Student Information Last Name: ____________________ First Name: __________________Middle: ____________
Grade Level: ____________Sex: _____________Social Security #: ______________________
Emergency Person: __________________________ Phone #: __________________________
Insurance: ____________________________________________________________________
Doctor: ______________________________________Phone#: __________________________
Church Affiliation: ______________________________Pastor: __________________________

Education Background: List chronologically all schools attended, including nursery school and Kindergarten. If any years were tutored study, please describe and give dates of tutorial sessions.
Date                     Grade                     Name of School                     Address of School








Scholastic Grades: (Check One which mostly closely resembles your child's grade reports.)
      ____Superior    ____Above Average    _____Average    _____Below Average
Is your child transferring from another school? _____ If yes, please explain on the back of this page.
Has your child ever been retained? ____ If so, please state which grade and write explanation on the back of this page.
Has your child ever failed a grade? ____ If yes, please state which grade and school year. _______________
Has your child ever been suspended? _____, Expelled? _____, or asked to withdraw? ______
If so, please give full particulars on the other side of this page, including principal's name and address of the school.

Reasons for Interest in Kankakee Trinity Academy:
Why do you, as parent or guardian of this student, desire to enter your child in Kankakee Trinity Academy?



Does your child want to attend KTA? Yes or No. Why? __________________________________________
(For students 5th grade level and above) In your own handwriting, please write why you do or do not want to attend KTA.




How did your family become acquainted with Kankakee Trinity Academy? __________________
___________________________________________________________________________
Other Children in Family:
      Name                               Grade                               School they attend




General Physical/Mental Condition of Child:
Does your child wear eye glasses? _______ All of the time? ________

Has your child, to your knowledge, used any type of non-prescription drugs, alcohol, tobacco, or has he/she ever been in any type of trouble with the law? _____ If yes, please explain on the other side of this page.

Has your child demonstrated or been diagnosed with any of the following: Learning Disorder, Behavior Disorder, Hyper-Activity, Attention Deficit Disorder or Attention Deficit Hyper-activity Disorder, or similar difficulties? ____________________________________________________________________
____________________________________________________________________

Is your child currently taking or has previously taken any medication for any of the above? Yes or No. Name of Medication ______________________________________Currently? Yes or No.

Has your child been diagnosed with a mental illness? Yes or No. Explain. _____________________________________________________________
_____________________________________________________________

Comment on your child's personality traits. (Ex: well-behaved, poised, responsible, congenial,
temperamental, aggressive, domineering, fearful)_________________________________________________________
_________________________________________________________

Parents Pledge:
We understand that attendance at Kankakee Trinity Academy is dependent on our child's achievement level, conduct, attitude, also, our cooperation, as parents, with the school in regard to the educational program, and consistent and prompt payment of tuition and other fees.
We, therefore, pledge our cooperation with Kankakee Trinity Academy in encouraging our child to follow the school's Christian teachings and standards. We further pledge to uphold the authority of the teachers and administration of the school, recognizing the importance of discipline and, as parents, support the administration's policy for discipline.
The required registration fee is enclosed for each child we are enrolling. We understand this fee is a reservation/registration fee for one year, and that the fee will be returned if our child is not accepted for admission. We realize this fee for reservation/registration is NON-REFUNDABLE if WE decide against sending our child to Kankakee Trinity Academy. We further understand that a student's records will not be released, upon transfer to another school, unless our financial accounts are paid in full.

Parent #1 Signature: ________________________________Date: __________________

Parent #2 Signature: ________________________________Date: __________________

Kankakee Trinity Academy admits students of any sex (gender), race, color, national or ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students in the academy. Kankakee Trinity Academy does no discriminate on the basis of sex (gender), race, color, national or ethnic origin in the administration of it's educational policies, admissions policies, scholarship and loan programs, and athletic or other school-administered programs. KANKAKEE TRINITY ACADEMY REQUESTS A COPY OF PREVIOUS YEAR'S REPORT CARD. A COPY OF IMMUNIZATION RECORDS, A COPY OF BIRTH CERTIFICATE, AND A CURRENT YEAR'S PHYSICAL IS REQUIRED UPON ADMISSION. ALL NEW STUDENTS ARE ACCEPTED ON A PROBATIONARY STATUS LASTING ONE SCHOOL YEAR.

The Administrator may want your child to attend the school for three days as a visitor, so that his/her behavior can be observed to assist us in determining if your child will fit into our program, and to see if our program will meet your child's behavioral or academic needs.

Are you willing for your child to visit? (Circle One) Yes or NO

Parent & Student should initial each item:
1. All new students must take an academic entrance examination. (This does not apply to Pre-Kindergarten or Kindergarten.) _____ _____
2. All new students are accepted on a probationary period lasting one full school year. Which means that at any time during that year the student could be asked to no longer attend the school if the KTA Board of Directors feels they are presenting behavior problems, etc., beyond the scope of our staff to handle. _____ _____
3. The KTA Board of Directors has the final authority regarding the acceptance of a new student. _____ _____
4. The KTA Board of Directors may expel a student who demonstrates inappropriate behavior. _____ _____
5. If a student is expelled and the legal guardians wish to appeal the expulsion, the appeal must be made in writing to the Board of Directors and the board must be unanimous in its' vote for a student to be re-admitted. _____ _____
6. Swearing or vulgarity of any kind will not be tolerated and very likely will result in expulsion. _____ _____
7. This school practices a non-discriminatory policy regarding race, sex (gender), and national origin. The school is interracial. _____ _____
8. The school is a guest of Open Bible Center; therefore, the school and its' students are obligated to take good care of the property and not damage church or school property. For example, chewing gum is not allowed in the school, and the second offense will result in suspension. _____ _____
9. Book fees are NOT refundable in whole or in part. _____ _____
10. For a student's application for admittance to be considered by the school, an application for admission must be filled out prior to an upcoming Board meeting. (Board meetings are usually held the second Monday of each month.) _____ _____
11. The behavior and academic performance of each student is reviewed at the end of each school year to determine if that student will be re-admitted for the following school year. _____ _____

A signature on the following line means that the above information has been communicated to the legal guardian(s) of this student, and that you agree that the school has full discretion in the discipline and grade placement of your child, and that the school reserves the right to dismiss any child who, by behavior and attitude, hinders the educational process of the school or who does not maintain the academic standards of the school. You further acknowledge that your services may be called upon to lend practical help in the operation of the school. You also agree to support the work of the school in prayer.
Parent #1 Signature: _____________________________Date: _______
Parent #2 Signature: _____________________________Date: _______
Student Signature: _______________________________Date: _______



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