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Headwaters

Headwaters Registration

Welcome to our online registration!

Directions for registering your child for Headwaters Educational Enrichment & Headwaters HUB

1. Read all the documentenation in the links below. You will be required to confirm that you have read and will comply with the information in the Parent-Child Handbook.

Headwaters Parent-Child Handbook
Headwaters Ministry Calendar 2020-2021
How to open a homeschool

2. Fill out all required information in the registration form below. You application will not submit if all required fields are not completed. You will see a confirmation screen if your form submitted successfully. Please include any and all information in detail. These forms are the first step towards ensuring that your child's records are accurate,

3. After submitting this form there are a couple of steps that still have to take place.

Registration Fee will need to be paid. Registration is not guaranteed until you have submitted your $150 registration fee (per family). You will be notified of the enrollment status by email.
- -- Registration fees will be refunded if your application is not approved. In the event you are placed on a wait list, we will retain your registration fee to hold your place on the list.
- -- Registration fees can be mailed to our church office at 2659 S Chipley Ford Rd. Please make checks are payable to South River Baptist Church with Headwaters Registration Fee in the memo field. If you would prefer to pay via checking account, debit or credit card you can use this link > https://onrealm.org/headwaters/give/regfee
We will review your application
We will check for availability in your child's grade level. If full, you may be put on a waiting list. Enrollments are based on a first-come, first-serve basis.

4. Your child/children will be registered and a Welcome email will be sent with next steps. If your child cannot be registered, the office will contact you in order to notify you of our decision and the reasons why we have denied registration.

5. If you have any questions, please contact our church office at 704-876-1520. We look forward to enriching your child’s education this year!

STUDENT INFORMATION:
Applying for Headwaters Educational Enrichment Program for Grade:*
Note: Pre-K must be at least 4 by 8/17/20.
Applying for Headwaters HUB Program for Grade:*
Note: HUB is designed for 3 or 5 day virtual learners continuing their enrollment in ISS or ARS schools. 1st-5th will be a per day cost and 6th-12th will be a flat fee per week. Please see Parent-Child handbook for details.
Applying for After-school Program?*
After-school program is for K-8th grades and will run from 3p-6p Mon to Fri. It will be an additional $50 per week for each child enrolled regardless of how many days they attend.
- Yes
- No
If applying for Headwaters HUB Program, please select days your child will be attending.
Your Lump Sum or Monthly Payment will be calculated base on selection.
- Select All
- Mon
- Tue
- Wed
- Thu
- Fri
Gender:*
- Male
- Female
Birth Date*
MM
DD
YYYY
Child's Name*
First Middle Last Goes By
Home Address:*
Street Address City State ZIP Code
EMERGENCY CONTACT INFORMATION:
1st Emergency Contact Name*
First Last
1st Emergency Contact Relationship*
1st Emergency Contact Phone*
2nd Emergeny Contact Name*
First Last
2nd Emergency Contact Relationship*
2nd Emergency Contact Phone*
FAMILY INFORMATION:
Father or Guardian Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Mobile Phone*
Email*
Enter Email Confirm Email
Occupation:*
Employer:*
Name of church where you are a member:*
Attending Regularly?*
- Yes
- No
Church City/State*
City State
Mother or Guardian Name*
First Last
Address:*
Street Address City State ZIP Code
Mobile Phone*
Email*
Enter Email Confirm Email
Occupation:*
Employer:*
Name of church where you are a member:*
Attending Regularly?*
- Yes
- No
Church Address*
City State
Parent's Marital Status:*
Child resides with:*
Number of children living in the home:*
Are there any custodial difficulties?*
PREVIOUS SCHOOL INFORMATION
School Last Attended (list homeschool if applicable):*
If child was previously in homeschool please list the name of your homeschool. For children that are going into Pre-K or K please list name and address of daycare instead of school, if applicable. If no previous school please put NA.
School Address:
Daycare or homeschool address if applicable

Street Address City State ZIP Code
Has the child ever been retained?*
- Yes
- No
If yes, which grade?
Has the child ever been suspended?*
- Yes
- No
If yes, please state reason:
Has the child ever had any difficulty with the Civil Authorities?*
- Yes
- No
If yes, please give the details and reason for the difficulties:
Are there any factors in the child's life (i.e. absence of father or mother, physical limitations, or disabilities) that may affect his/her progress or activity in school?*
- Yes
- No
If yes, please indicate:
Has the child experienced any learning difficulties or been diagnosed as ADD/ADHD?*
- Yes
- No
If yes, please explain:
Agreement with Fees and Policies
Links to documents and handbooks where applicable, are included at the top of this form.
We agree to pay the Family Registration Fee of $150 plus additional year end testing fees per child, if applicable, as describe below.*
Fee due with submission of this form (see details at the top of this form for payment options.) Registration is not complete until $150 fee is submitted. ----------------- This registration fee includes one end of year test for one child, if the family has additional students enrolled there will be a $35 fee for each additional child. Testing is only for children in the Educational Enrichment Program.
- Yes
We agree to pay a one time Resource Fee of $200 per child for Educational Enrichment Program or $50 Technology Fee per child for HUB Program.*
Fee due upon application approval
- Yes
We agree to commit to paying Headwaters fees in the following manner:*
Lump sum fee and 1st monthly installment is due before first day attending. The Educational Enrichment Program is a 10 month commitment and the HUB & After School Program is a minimum of 5 month commitment (Aug-Dec and/or Jan-May)
- I prefer to pay a lump sum payment
- I prefer to pay monthly installments
We understand that images of our child may be captured and used through video, photo and digital camera, to be used solely for the purposes of promotional material and publications, and we waive any rights of compensation or ownership thereto.*
- Yes
Upon admission approval and we will submit the required additional Medical and Liability form*
Form must be submitted prior to attending
- Yes
We have received and read the Parent-Child Handbook V1.2. We understand and will abide by the policies as presented in the document.*
- Yes
We confirm that all the information submitted in this form is accurate and truthful*
- Yes
Date*
Date Format: MM slash DD slash YYYY
Signature of Father or Gaurdian*
Signature of Mother or Guardian*

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