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Membership Form 24-25

indicates a required answer

1. *

Name of Parent(s):
2. *

Street Address:
3. *

City, State, Zip Code:
4. *

Phone Number:
5. *

Emergency Phone Number:
6. *

Email Address:
7. *

Person responsible for payments:
8. *

Member Status:
Current Member New Member

New Members Only - Please complete the areas highlighted in red.  Both the reference letter  and questions are required to be considered for membership.

Please have either your pastor or a current Koinonia member submit a reference letter explaining why you would be a good addition to the Koinonia community.  Reference letter is available HERE as well as under "Forms" on our public page. as  as  as well as ounde Forms on our  as as ..
9. 

Which current/former Koinonia members do you know?
10. 

What makes you a good candidate to be a member of Koinonia Home School Group?
11. *

Name of Child #1:
12. *

Birthdate of Child #1:
13. *

Gender of Child #1:
14. 

Name of Child #2:
15. 

Birthdate of Child #2:
16. 

Gender of Child #2:
17. 

Name of Child #3:
18. 

Birthdate of Child #3:
19. 

Gender of Child #3:
20. 

Name of Child #4:
21. 

Birthdate of Child #4:
22. 

Gender of Child #4:
23. 

Name of Child #5:
24. 

Birthdate of Child #5:
25. 

Gender of Child #5:
26. 

Name of Child #6:
27. 

Birthdate of Child #6:
28. 

Gender of Child #6:
29. *

Have any of your children ever been expelled from any public, private, parochial, homeschool, or other educational organization?

* If yes, please email [email protected]  a complete explanation. Include child’s name, name of organization, date, reasons for and length of expulsion.
Yes No
30. 

Please do NOT use my child(ren)'s picture or likeness in the following Koinonia media.  Explain below if applicable.  (All students will be included in class and individual yearbook pictures)
31. *

Church Attended:  (Members are expected to attend a Bible believing church)
32. *

I/we have read Koinonia’s Mission Statement and Statement of Faith and understand the organization will be guided and make decisions based on these Statements.

 (1 required)
Agree Disagree
33. *

I/we have read the Policies page on Koinonia’s website, have taken the responsibility to inform my family members of the Policies, and agree to abide by those policies, procedures, and expectations in cooperation with Koinonia’s staff and Board of Directors. 

 (1 required)
Agree Disgree
34. *

I/we understand that Koinonia leadership and tutors are not responsible for my children’s education. I, as well as my children, agree that we are responsible for their physical, mental, social, and spiritual well-being. 

 (1 required)
Agree Disgree
35. *

I/we understand that this membership will expire at the conclusion of this school year and that the membership fee is non-refundable. 

 (1 required)
Agree Disgree
36. *

I/we understand the contagious nature of disease such as COVID and voluntarily assume the risk that I and my family may be exposed to or infected by any diseases due to the actions, omissions, or negligence of myself and/or others, including, but not limited to, Koinonia contractors, volunteers, members, and participants and their families.  I/we waive liability against the Koinonia Home School Group and West Cannon Baptist Church, and accept sole responsibility for any illness, injury, disability, or death to myself or my family, including all claims that may arise resulting from any of these.

 (1 required)
Agree Disgree

Waiver In consideration of my family’s participation in events and activities of Koinonia, THE UNDERSIGNED HEREBY FULLY WAIVES, RELEASES, DISCHARGES, AND AGREES TO INDEMNIFY AND HOLD HARMLESS (“Release”) Koinonia, and the owner of any rented facilities, and their respective officers, agents, and employees, from any and all rights, claims, liabilities, and actions for losses, damages, or injuries to property or person that may arise out of or result from use of facilities, equipment, or properties by me or my child, whether or not caused by the negligence of Koinonia, the owner of rented facilities, or their respective officers, agents, and employees. I have read the Agreement and Waiver sections and agree to and acknowledge acceptance of all its terms. 

Typing your name is considered a signature and agreement with the above statements.  Both parents signatures are required when both parents participate in making educational decisions for the child(ren).  Please contact an administrator with any exceptions.
37. *

Parent #1 Signature:
38. *

Date:
39. *

Parent #2 Signature:
40. *

Date:
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