Directions for filling out the ŽŽů^ĐŚŽŽůApplication:
1. Use Adobe Acrobat Reader to view form.
• Click link below if download of Adobe Acrobat Reader is necessary.

2. Please DOWNLOAD and OPEN file locally before completing by clicking
the download icon in browser being used.
• Firefox browser• Google Chrome browser• Internet Explorer browser

3. Please submit the completed forms to the School Office.

:ffcJZ_ffci`j`e^b5 $-k_^iX[\Application Form)')4(please type or print in black or blue ink)

Enrolled at HCA for SY 2024-25: YesDates to Attend:NoƑ Next Grade:101460 7220DZHHNSHUVWXGHQW
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603 8 $//:((.6First Name:

Birthdate:Current Age:

$220 a week per student/$195 a week forstudents enrolled
in HCA for SY 2024-25

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Last Name:24282DZHHNSHUVWXGHQW
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English Name:

Home Phone:Male:Ƒ Female: ƑMailing Address:
First Name:

Father’s/Guardian’s Last Name:

Email:

Work Phone:

Cell Phone:First Name:

Mother’s/Guardian’s Last Name:
Cell Phone:Work Phone:

Email:

Emergency ContactMr.

Ƒ Mrs. Ƒ Miss Ƒ

Last Name:

Home Phone:First Name:
Cell Phone:Work Phone:

PhotoRelease
MedicalInformation:

Do you give permission to use any pictures of your child for any Harvest Christian Academy published media?
Reading:
Shotrecords
attachMedicalInformationYesƑ NoƑƑ No Ƒ If yes, please explain:
Does your child have any food allergy? Yes Ƒ No Ƒ If yes, please explain:
Does your child have any serious illness? Yes Ƒ No Ƒ If yes, please explain:
Does your child have any heart problems? Yes Ƒ No Ƒ
Does your child have any convulsions? Yes Ƒ No ƑDoes your child have any physical handicap? Yes Ƒ No Ƒ If yes, please explain:
Does your child take medicine on a regular basis? Yes Ƒ No Ƒ If yes, please explain:
Does your child have any restrictions on physical activity? Yes Ƒ No Ƒ If yes, please explain:
Do you give permission for your child to receive Tylenol or any over-the counter medication if the need arises? Yes Ƒ No Ƒ
Does your child have any drug allergy? Yes

By signing below, I agree to pay the applicable fees and submit the required documents with this application. I understand that the fees are non-refundable. I also
understand that I am responsible for other additional costs (food from the cafeteria, extended care, etc.) incurred while my child is attending any summer programs ofHarvest Christian Academy. I hereby give my child permission to attend field trip activities upon notification. I hereby release HCA and its agents from liability for any
injuries resulting from my child’s attendance. As a parent, I agree to support the Administration of Harvest Christian Academy; however, should I feel I can nolonger support the Administration, I will promptly withdraw my child. To my knowledge, all information is complete and correct.

DATEPRINT NAME

PARENT’S/GUARDIAN’S SIGNATUREFOR OFFICE USE ONLY:

Date:
Excel ĿTime:
FACTS Ŀ

P.O. Box 23189 Barrigada, Guam 96921 ɋ (671) 477-6341 ɋ hcaguam.org