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Crossroads Christian School Incorporated
RE-ENROLLMENT PACKET CHECKLIST 
Re-Enroll Date: _____________
Date: _______________
_____$25 NON-REFUNDABLE APPLICATION FEE
_____ RE-ENROLLMENT FORM/RELEASE FORM
_____TUITION AGREEMENT
_____CODE OF CONDUCT AGREEMENT FORM
_____DRESS CODE AGREEMENT FORM
_____STUDENT TECHNOLOGY AGREEMENT
_____ SCHOOL YEAR FOR WHICH YOU ARE APPLYING
* This checklist must be complete before Crossroads Christian School and its affiliations will consider any
interviews. Any incomplete packet will not be processed. You can return these forms to the school office
or mail them to the following address:
CCSI
PO Box 4649
Victoria, TX 77903
Re-Enrollment
God is doing great things on our campus, and we are excited to partner with you for another
year at CCSI. Plans for the 2015-2016 school year are already underway and we are looking
forward to serving your family by educating and discipling your student(s) in the upcoming year!
As always, we are blessed to serve your family. We look forward to another year of partnering
with you to thoroughly prepare your student(s) to fulfill God’s purpose for their lives, as we
glorify God through the discipleship of students and the pursuit of excellence in education!
Returning CCSI families are encouraged to re-enroll as soon as possible in order to guarantee
your spot. Thank you for your continued support! Your investment in your child’s Christ-centered
college-preparatory education is invaluable!
Crossroads Christian School and its affiliations do not discriminate or retaliate on the basis of gender, race, color,
national or ethnic origin, or physical or cognitive disability in administration of its educational policies, admission
policies, and other school administered programs. However, Crossroads Christian School and its affiliations do
reserve the right to use appropriate selection criteria for employees and students to fulfill its stated goals and
objectives.
Biblical Worldview ~ Qualified Teachers ~ Academic Excellence ~ Leadership Development ~ Every Student Matters
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Crossroads Christian School Incorporated
Re-Enroll Date: _____________
2015-2016 RE-ENROLLMENT AGREEMENT K-12
1. It is understood that the parent or guardian signing this application certifies that their child will follow all
rules and regulations, and will abide by all decisions made by the school administration. In the event that
rules are broken, proper action will be taken by the school administration. If there is no change in behavior,
the student will be dismissed without a refund. In the event that the student causes damage to another
person or property, the parent or guardian will be held liable for all damages incurred.
2. Medication and special needs of students must be indicated on the students’ personal data and medical
forms. Forms are due to the school office no later than the payment deadline for school. Students will not be
allowed to attend a single day of school unless all paper work is complete and on file in the school office.
3. In case of a medical emergency, all efforts will be made to contact the parent/guardian or emergency
contact and the child’s doctor. In the event that this is not possible, the parent hereby give permission to the
physician selected by the School Director to hospitalize, secure proper treatment for and to order injection,
anesthesia or other procedures to stabilize the camper’s condition. Please remember that students will NOT
be allowed to attend school, even for one day, without having provided the appropriate medical,
emergency and Data forms.
4. Crossroads Christian School has permission to use a photograph, voice or image on film, videotape or other
sound or visual recording device, at any time with or without name, in any private or public broadcast on radio,
television, display in public or private places, on or in connection with printed, optical or magnetic media, in
connection with any online service or on the Internet, or any other form of communication, for advertising,
publicity or related promotion in an effort to inform and educate the public about Crossroads or learning
differences. This consent is give without any compensation based upon any future use permitted by this
agreement.
Signature of Parent/Guardian
Date
Signature of Student
Date
MEDICAL TREATMENT/FIELD TRIP/SCHOOL PARTICIPATION/RELEASE FORM
Doctor:
Phone:
In case of emergency, I authorize Crossroads Christian School and its staff or representatives to consent to any medical
treatment and/or hospital care (all students will be taken to the nearest hospital, which in this case is Citizens, unless the
school is notified in writing of another preference), which is rendered to the minor, named above, under the supervision of
any licensed physician. It is the responsibility of every individual, his or her parents or legal guardian to provide for his or
her own medical coverage while participating in all Crossroads Christian School activities. In addition to the above, I grant
permission for the above named minor to participate in all school activities and pose for photos, without names to be used
for marketing purposes unless otherwise indicated in writing. My child has permission to go on all field trips. In addition my
child has permission to use the internet under the supervision of a qualified adult.
Signature of Parent/Guardian
Date
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Crossroads Christian School Incorporated
Re-Enroll Date: _____________
2015-2016 RE-ENROLLMENT FORM K-12
FIRST COME FIRST SERVE REGISTRATION DEADLINE January 31st 2015
Student Name
Date of Birth
Male
Entering Grade (2015‐2016)
Female
Home Phone Number
Parent/Guardian names
Mailing Address
City
State
Zip Code
Mother’s Work Phone
Cell Phone
Email
Father’s Work Phone
Cell Phone
Email
MEDICAL AND EMERGENCY DATA
Any allergies or medical conditions we need to be aware of: _____________________________________________
______________________________________________________________________________________________
Name and contact information of Primary Care Physician: _______________________________
_____________________________________________________________________________
Is the student current on all immunizations?__________________________________________
Provide a current immunization record from your physician’s office.
Emergency Contact Info: Please provide new information for two emergency contacts:
Name/related to student/how to contact:__________________________________________________________
Name/related to student/how to contact:__________________________________________________________
Program: Please select the program for which you are re-enrolling and the class(s) you wish
to take:
_____K-5
_____3 Day Program
_____ Monday/Wednesday
_____Dual Credit
_____Tuesday/Thursday
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Crossroads Christian School Incorporated Re-Enroll Date:
_____________
I have read and agree with the beliefs and mission statement of Crossroads Christian School
Incorporated and its affiliations. I understand that the curriculum provided is a homeschool
educational program. I understand that my child will attend tutoring a minimum of two days per
week and that ultimately, the burden of my child’s education lies with me. I agree to partner with
CCSI and its affiliations to help facilitate and implement home-based educational support
necessary for effective learning. CCSI and any affiliations operate and are educating under the
delegated authority of the parents.
I do hereby confirm that Crossroads Christian School Incorporated and its affiliations is not
affiliated in any way with Family Worship Center. I voluntarily sign this Release of Liability,
Assumption of Risk, and Agreement to Indemnify and agree to hold harmless and not to sue
Crossroads Christian School Incorporated or Family Worship Center and any administrators,
agents or employees of said organizations.
Please initial to indicate whether you are the parent or legal guardian of the student.
( ) Parent
( ) Legal Guardian
______________________________________________________________________
Parent or Legal Guardian’s Signature
Date
_________________________________________________
Print Name of Parent or Legal Guardian
______________________________________________________________________
Student’s Signature
Date
_________________________________________________
Print Student’s Name
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Crossroads Christian School Incorporated Re-Enroll Date:
_____________
Tuition & Fees
ANNUAL TUITION SCHEDULE SHOWING SIBLING DISCOUNT
Grade
1st (oldest) child
2nd child 5%
3rd + child 10%
K, 1st -5th
$3,300.00
$3,135.00
$2,970.00
$2,640.00
$2,508.00
$2,376.00
$2,565.00
$2,430.00
$2,375.00
$2,250.00
th
6 -8
th
th
th
9 -12
$2,700.00
* Homebound Students
1st – 12th
$2,500.00
3 Day Program
Grades 6-12
$4,000.00
*Tuition rates are for on-campus students, with the exception
$3,800.00
$3,600.00
of off-campus homebound students.
Application Fee
$25.00 non-refundable due with Application
Registration Fee
$475.00 (non-refundable & due at time of registration)
*registration fees increase after June 1st
Fall Registration Fee: A $475 non-refundable registration fee per child is required and due in full by June 1 st 2015 ($500 after
June 1st). Space is limited; this fee secures your child a spot at CCSI and includes the curriculum, technology fee, FACTS,
MyGradebook and all required school supplies.
Tuition Payment Options
 Two equal payments: July 1, 2015 & January 1, 2016.
 10-month plan: Ten equal monthly payments beginning July 1, 2015.
 12-month plan: Twelve equal monthly payments beginning July 1, 2015.
*Tuition is due on the 1st of each month or on the 1st and 15th if you choose the split month payment plan. Delinquent accounts
have a $35 late fee assessed. Please see below for payment options.
A signed FACTS Tuition Management Agreement form is required to enroll at CCSI. Enrolling in the tuition payment plan
allows you to select a payment option that best suits your financial needs. Example: a monthly payment plan of $270 due in full
on the 1st can be split into two payments: $135 due on the 1st and $135.00 due on the 15th.
Student Withdrawal
Tuition is on a 10 or 12 month term (depending on your payment plan) and starts every July 1st. Notice of withdrawal must be given
BEFORE the following month begins in order to receive a refund for that month. Example: If you choose to withdraw in December and notify us
after the 1st of that month, you are legally responsible for all tuition due in December, and will be withdrawn in January.
Monthly Payment Plan Amounts
STUDENTS
ANNUAL TUITION
10 MONTH
12 MONTH
Homebound
$2,500.00
$250 or $125/$125
Not available
Elementary
$3,300.00
$330 or $165/$165
$275 or $137. /$137.
Middle school
$2,640.00
$264 or $132/$132
$220 or $110/$110
High school
3 Day Program 6-12
$2,700.00
$4,000.00
$270 or $135/$135
$400.00 or $200/$200
50
50
$225 or $112. /$112.
$332 or $166/$166
50
50
Please initial this page to indicate understanding and agreement __________________
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Crossroads Christian School Incorporated Re-Enroll Date:
_____________
Crossroads Christian School Tuition Agreement
We are pleased to offer a secure, convenient method for enrolling in a FACTS payment plan. Enrolling in a
FACTS tuition payment plan allows you to select a payment option that best suits your financial needs.
Monthly Payments:
 Spread your tuition balance over Monthly Payments, Bi-monthly Payments or Semester
Payments.
 Payment Methods Offered: Automatic Bank Draft.
For more details about the options above, create an online account.
Simple Steps to Enroll in a Payment Plan Online:
1. You will first need to create an online account.
2. Then click on the Set Up a Payment Plan link.
3. Select the school year for which you will be paying.
4. Complete the steps as prompted.
Please use the following link to start the process:
https://online.factsmgt.com/signin/4JVLS
*Please note that this document is due at the time of enrollment.
Party responsible for payments
□ Applicant
□ Other - Payer name and phone number ___________________________________
Relationship to student __________________________________
Please sign the following statement:
The information given in this application and Tuition agreement form is correct. I understand that a non-refundable $25
application fee is due with this document. I understand that a non-refundable $475 registration fee is due with this document. I
understand that if I am accepted in the program I am responsible for the full tuition and agree that payments will be made in a
timely manner. I understand that an unpaid balance may result in termination of enrollment, and/or delay certification upon
completion of course requirements.
Applicant’s signature________________________________________________
Payer’s Signature __________________________________________________
Administrator’s Signature____________________________________________
Date of understanding and agreement of this document __________________
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Crossroads Christian School Incorporated Re-Enroll Date:
_____________
CODE OF CONDUCT STUDENT AGREEMENT
The behavior expected in this type of educational program should ultimately reflect excellence in
character and integrity. Students are expected to fully participate, follow all guidelines and conduct
themselves in such manners that properly facilitate an atmosphere conducive to a high-quality learning
experience for all. Students, this means that you do your part and share in maintaining the level of
excellence expected. You are in partnership with educators and peers and responsible for our
environment. In order to maintain the level of excellence that is expected, you will be sent home for
repeated behavior that violates the mission here at Crossroads Christian School and its affiliations.



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At all times, be humble in speech and kind in action
Contribute to the building up and encouragement of one another
Choose to promptly follow requests and requirements without complaint
Use classroom time wisely
A violation — whether occurring at school or during school-sponsored events, activities, or functions,
whether on campus or off campus— for inappropriate behavior can involve any of the following : teasing
or bullying anyone, or using offensive gestures or actions; speaking with disrespect, mockery, swearing,
unkindness, or vulgar language.
Disciplinary action will vary based on the degree of the offense and determined by the CCSI staff.
Furthermore, anyone involved with theft, vandalism, the use of illegal drugs and alcohol, leaving the
premises and other such offenses will immediately be sent home or turned over to the proper
authorities. You will be billed and are responsible for repair costs and damages to any property.
Students are expected to honor the Codes of Conduct previously stated and sign below
acknowledging agreement:
[
] will begin this contract on this date
_ to help in assuring his/her success. This contract will be used to assist in determining
their future at Crossroads Christian School and its affiliations.
Administrator’s Signature
Date
I have read and agree to abide by the code of conduct included in this application.
Signature of participating student
Date
I expect my child to abide by this code of conduct.
Signature of parent or legal guardian of participating student
Date
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Crossroads Christian School Incorporated Re-Enroll Date:
_____________
DRESS CODE
Clothing should be modest, functional and neat.
Crossroads acknowledges the student’s desire to dress “in style”; however, what is fashionable to wear may not
be appropriate for school or school-sponsored events.
Please read the following carefully:
Clothing must be neat, clean (no holes above the knees), modest and appropriate for school.
Dresses, skirts, skorts and shorts must be no shorter than fingertip length.
No midriffs shall be showing. No under garments shall be showing.
No low-waist or low-rise pants. Pants must fit so they do not sag, exposing one’s undergarments (including tops
of boxers.)
No item of clothing shall expose undergarments while bending over.
No spaghetti strap or strapless garments. No see-through fabrics.
Shirts must be modest and not show undergarments.
No hats inside the building.
No flip-flops. Footwear must be worn at all times. (State Health Regulation.)
No sweat pants or athletic wear.
High school and middle school boys must limit earrings to single small studs, no loops or gauges. Boys in
elementary school must not wear earrings.
Clothing that endorses, promotes or glorifies drugs, alcoholic beverages, tobacco, anti-Christian messages, or
music groups with anti-Christian lyrics, sexual innuendoes, anarchy, skulls, references to death or suicide, or
other disrespect to God or the nation is not allowed. Furthermore, graphics or pictures, emblems, or writings
that are lewd, offensive, vulgar, or obscene or graphics related to gangs, illegal activities or substances,
glorifying blood, gore, skulls, etc. are not allowed.
Visible body piercing or tattoos (permanent or not) are not allowed. Those entering Crossroads Christian School
who have body piercing(s) other than earrings, must remove the hardware from the piercing while on campus
or at any school-sponsored activity. Students should refrain from body piercing and tattooing, with the
exception of pierced ears. Students making tattoo(s) visible during school or at school-sponsored functions risk
disciplinary action.
Consequences for Inappropriate Dress:
Any student out of dress code is considered in violation of school policy and will be sent home.
* this policy is subject to change. CCSI reserves the right to make changes to dress code policy at any time during the year. Parents will be
notified.
I have read and agree to abide by the dress code included in this application.
Signature of participating student
Date
I expect my child to abide by this code
Signature of parent or legal guardian of participating student
Date
Page 8 of 9
Crossroads Christian School Incorporated Re-Enroll Date:
_____________
Student Technology Agreement for Acceptable Use
Please read the terms of this policy carefully before signing this agreement as part of the Crossroads
Christian School and its affiliations registration packet.
The following terms define the policy of all technology resources by students while on or near
Crossroads Christian School and its affiliations, known to be currently located at 501 Sam Houston Drive,
Victoria, Texas, 77901. All technology resources include, but are not limited to: computers, laptops,
iPads, iPods, tablets, cell phones, cameras, and other electronic devices.
Crossroads Christian School and its affiliations will hold ALL students liable for use of provided
technology or personal use of technology. Any violation of this agreement will result in immediate
disciplinary action. Students are expected comply with policy and procedures. This includes but is not
limited to the use of all technology resources by students while on or near CCSI property, and at CCSI
sponsored events both on- or off-campus.

Student and parent agree that the student will be responsible for all online activities and will not
misuse or abuse the privilege of access to the internet or any communications via the internet.

For the safety and privacy of all CCSI staff and students, the student cannot take, publish or post
photographs or videos of said staff and students while on CCSI campus, without explicit
permission from both student and/or staff. In addition, student recognizes that any electronic
exchanges deemed harassing or bullying in nature will be evaluated and dealt with accordingly.

Student will be respectful of all equipment and be responsible for any damage to property
belonging to CCSI.

Student and parent agree that the student will not have the right of privacy when accessing the
Internet or network while using CCSI’s wireless provider.
Student and parent agree that access to the internet is a privilege and is solely for educational purposes,
i.e. academic research and enrichment. Therefore, ANY websites not used to edify the CCSI community
and/or for educational purposes will be deemed inappropriate in use and Disciplinary Action will be
enforced.
X_____________________________
X_____________________________
parent
student
X_____________________________
X_____________________________
parent
date
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