PICKENS ACADEMY * 225 Ray Bass Road * Carrollton, AL 35447 * 205-367-8144

Application for enrollment in Pickens Academy and membership in Pickens Private Foundation
I hereby make application for my child/children/ to enter Pickens Academy

Section I.        Student/s Information 

Full name of student__________________ Full name of student_____________________

Usually called________________________ Usually called__________________________

Social Security Number_________________ Social Security Number__________________

Date of birth__________________________ Date of birth___________________________

Grade in which to be enrolled_____________ Grade in which to be enrolled_____________


Full name of student___________________ Full name of student_____________________

Usually called________________________ Usually called__________________________

Social Security Number________________ Usually called__________________________

Date of birth_________________________ Date of birth___________________________

Grade in which to be enrolled____________ Grade in which to be enrolled_____________

Section II.       Family/Data




Home Phone__________________________ Work Phone___________________________

Occupation____________________________ SSN_________________________________




Home Phone___________________________ Work Phone____________________________

Occupation_____________________________ SSN___________________________________

Section III.

Does/Do child/children live with _____both parents; _____mother; ______father; ______other*

*Name and Address__________________________________________________________

*Relationship to child/children: _________________________________________________

Section IV.

In case of emergency, contact____________________________ phone__________________

or contact____________________________ phone__________________

Section V           Declare your Public School District______________________________________

Section VI           Please state the reasons you desire to transfer/enroll your child/children at
Pickens Academy.



Section VII          Transfer information:  (past three years)

Previous schools attended                                              Dates attended

  1. ___________________________________________________________________________


  1. ___________________________________________________________________________


  1. ___________________________________________________________________________

Section VIII

Have any of your children experienced any trouble in any previously attended school?

Yes____ No____ If yes, please explain___________________________________


Section VIX.    Financial Information

The following is a summary of payments due for pre-registration and registration.
Please carefully review the Enrollment Agreement for specific information regarding payments.
Schedule of Payments – Due at Registration

**OPTION 1**_________ check here
   Building fund                                                 $125.00 per family   _______
   Book/Technology Fees                                 $200.00 per child Grades 1-12 _______
   Fees and Services  (K-3 – 12)                       $100.00 per student    _________

Donation to Pickens Private School Foundation
(New families entering Pickens Academy for 2017-2018 school year)
Grades 1-12        $500.00
K-5                       $400.00 pay another $100 upon entering first grade

K-4                       $300.00 pay $100 more entering K-5 and first grade
K-3                       $300.00 pay $100 more entering K-4 and K-5
*This donation is tax deductible and non-refundable.

2017-2018 tuition schedule

                        1 child            2 children         3 children     4 children           

Monthly         12 x $280         12 x $560          12 x $840      12 x $1120

1 x pay             $3310              $6620              $9930             $13,240

Tuition may be paid in full at time of registration or in 12 monthly bank drafts, (August – July).
A Senior’s tuition must be paid in 10 monthly drafts (Aug-May). For monthly payments a voided check or deposit slip must be submitted at the time of registration.

**OPTION 2**   _______   CHECK HERE   All fees excluding pre-registration fees may be included in your monthly draft.

In the event a family withdraws from Pickens Academy anytime after Spring Registration is complete through December 31st, they will be required to pay a $2000.00 penalty per child. If a family withdraws during the 2nd semester a $1000.00 penalty per child will be assessed.  All fees owed to any organization must be paid in full before any records or transcripts are released.

If registration occurs after the beginning of school, all of the above applies with these exceptions.  Monthly tuition begins with month at the time of registration with subsequent bank drafts for the remainder of the school year.  Families enrolling during any month must pay for a full month’s tuition for that current month.

I certify that my child/children is/are of sound moral character and is/are in good physical and mental health.  I have read the admissions standards, the financial information, and will abide by the polices described therein.  Furthermore, I understand that any false information or the absence of pertinent facts that would deny acceptance will be grounds for immediate dismissal.

Signature of parent or guardian______________________________________


**IMPORTANT** This form must be completed and turned in at registration

 Pickens Academy * 225 Ray Bass Road * Carrollton, AL 35447

Enrollment Agreement 2017-2018

In consideration of the acceptance of this Enrollment Contract by Pickens Academy the undersigned agrees to pay the required tuition and fees as specified below:

Registration: (Non Refundable)

New Family: $100.00 per family plus $50.00 per child.

Existing Family: $50.00 per family plus $50.00 per child

Choose one option:

_______Annual Payment                                   _______Monthly Draft Payment

One payment of _________                               twelve payments in the amount of

Is due prior to August 1st                                       _______ are drafted on the 1st day of each month, Aug-July

I understand that my obligation to pay the tuition and fees for the full academic year is unconditional and that after registration no portion of tuition/fees paid or outstanding will be refunded or cancelled in the event of absence, withdrawal or dismissal from Pickens Academy.  In the event that a family withdraws from Pickens Academy anytime after Spring Registration is complete through December 31st, they will be required to pay a $2000.00 penalty per child.  If a family withdraws during the second semester a $1000.00 penalty per child will be assessed.

I also understand that a fee of $20.00 will be assessed for any returned checks.  Should collection become necessary, all reasonable costs of collection, including court cost expenses, and reasonable attorney’s fees will be paid by the undersigned.

In signing this Enrollment Contract for the coming academic year, I am agreeing to accept the rules and regulations of Pickens Academy as stated in the Student’s Handbook and the rule concerning payment of tuition and fees as referred to above.  Futhermore, I agree to the policy of Pickens Academy that no student’s grades or transcripts will be released unless an account has been paid in full.

This contract shall be interpreted in accordance with the laws of the State of Alabama.
My signature below affirms that I have read, understood and accept the terms and conditions of this contract.

Signatures of parent/s or guardian/s financially responsible for student/s

1)______________________________Address: _______________________    Date:___________

2)______________________________Address: _______________________    Date:___________

Student/s Name/s:

1)__________________________                                 3)_________________________

2)__________________________                                 4)_________________________


Accepted:  Pickens Academy                Date_______________            By:_______________________

2017-2018 Tuition Schedule

One Child Two Children Three Children Four Children
Monthly 12 x 280 12 x 560 12 x 840 12 x 1120
1x pay $3310 $6620 $9930 $13,240