ASSOCIATION OF CHRISTIAN SCHOOLS INTERNATIONAL INDONESIA 2015-2016 Membership Form MEMBERSHIP PERIOD 1 year membership: 1 August 2015 – 31 July 2016 2 year membership: 1 August 2015 – 31 July 2017 It is important that ALL information be clear, current and complete. Please review it carefully because this information appears in the ACSI annual membership directory and affects services to your school. Return this signed and completed form to: Penting bahwa SEMUA informasi harus terbaru dan diisi dengan jelas dan lengkap. Mohon diperiksa ulang dengan seksama karena informasi ini akan tertera dalam direktori membership tahunan ACSI dan mempengaruhi pelayanan terhadap sekolah Anda. Kembalikan formulir ini lengkap dengan tanda tangan ke: Association of Christian Schools International (ACSI) Indonesia Kompleks GRAHA ASRI RK 10, Jl. Ngagel No. 179-183 Surabaya 60246 East Java – Indonesia Phone/Fax. (+62)31-5053891, (+62)31-5048490 Mobile. (+62)851.0493.5548, (+62)878.5270.4222 Email:
[email protected] Website: www.acsi.or.id Note:
Please initial the appropriate box for each item below (Beri tanda (X) pada kotak yang sesuai untuk setiap point di bawah inI) This form can be copied. (Formulir ini dapat diperbanyak / difotokopi.)
Note:
If you have any difficulty, please give the data of 2014-2015 academic year. If there is any discrepancy, ACSI will contact the school in September 2015 to update the data and make adjustment accordingly to the annual membership fee. (ACSI will return the excessive payment and will sent invoice for lack of payment) (Jika kesulitan silahkan memberikan data tahun ajaran 2014-2015, jika ternyata ada perbedaan ACSi Indonesia akan menghubungi pada bulan September 2015 untuk memutakhirkan data dan melakukan penyesuaian pada iuran tahunan keanggotaan (ditagihkan bila kurang & dikembalikan bila ada kelebihan)).
Contact Information SCHOOL NAME ADDRESS (Including City, Postal Code, & Province) PHONE FAX EMAIL WEBSITE FOUNDING YEAR : (Tahun Pendirian)
SCHOOL DIRECTOR (Nama Direktur Sekolah):
Do NOT list our email address in the directory Do NOT post our school on the ACSI website
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Please fill in the number of students for all unit schools: Mohon masukkan jumlah siswa untuk semua unit sekolah: PG1……….. PG2………… TKA…………. TKB………….. (Nursery & Kindergarten) TOTAL NUMBER OF STUDENTS: ……… Principal Name, Title (Nama Kepala Sekolah, Title) Principal Email (Email Kepala Sekolah) NUMBER OF TEACHERS Full-time (Guru Tetap) Part-time (Guru Tidak Tetap) (Jumlah Guru) ……………… …………..… DIPLOMA S1 (Bachelor) S2 (Master) ……Teachers …..Teachers .….Teachers TEACHER’S EDUCATION (Pendidikan Guru)
STATUS (Choose one) MEMBERSHIP SOUGHT (Keanggotaan yang Diinginkan)
Teachers College Graduate (Sarjana lulusan Pendidikan) ................ National School National Plus School International Membership National Membership
Government Assigned (DPK) …………… S3 (Doctor) ……Teachers
Non Teachers College Graduate (Sarjana lulusan Non Pendidikan) ..................... International School
SD1……….. SD2………… SD3…………. SD4…………. SD5………… SD6………….(Primary) TOTAL NUMBER OF STUDENTS: ……… Principal Name, Title (Nama Kepala Sekolah, Title) Principal Email (Email Kepala Sekolah) NUMBER OF TEACHERS Full-time (Guru Tetap) Part-time (Guru Tidak Tetap) Government Assigned (DPK) (Jumlah Guru) ……………… …………..… …………… DIPLOMA S1 (Bachelor) S2 (Master) S3 (Doctor) ……Teachers …..Teachers .….Teachers ……Teachers TEACHER’S EDUCATION (Pendidikan Guru) Teachers College Graduate Non Teachers College Graduate (Sarjana lulusan Pendidikan) ................ (Sarjana lulusan Non Pendidikan) ..................... STATUS (Choose one) National School International School National Plus School MEMBERSHIP SOUGHT International Membership (Keanggotaan yang Diinginkan) National Membership SMP1………….. SMP2…………… SMP3………….(Junior High School) TOTAL NUMBER OF STUDENTS: ……… Principal Name, Title (Nama Kepala Sekolah, Title) Principal Email (Email Kepala Sekolah) NUMBER OF TEACHERS Full-time (Guru Tetap) Part-time (Guru Tidak Tetap) Government Assigned (DPK) (Jumlah Guru) ……………… …………..… …………… DIPLOMA S1 (Bachelor) S2 (Master) S3 (Doctor) ……Teachers …..Teachers .….Teachers ……Teachers TEACHER’S EDUCATION (Pendidikan Guru) Teachers College Graduate Non Teachers College Graduate (Sarjana lulusan Pendidikan) ................ (Sarjana lulusan Non Pendidikan) ..................... STATUS (Choose one) National School International School National Plus School MEMBERSHIP SOUGHT International Membership (Keanggotaan yang Diinginkan) National Membership
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SMA1…………… SMA2…………… SMA3…………..(Senior High School) TOTAL NUMBER OF STUDENTS: ……… Principal Name, Title (Nama Kepala Sekolah, Title) Principal Email (Email Kepala Sekolah) NUMBER OF TEACHERS Full-time (Guru Tetap) Part-time (Guru Tidak Tetap) Government Assigned (DPK) (Jumlah Guru) ……………… …………..… …………… DIPLOMA S1 (Bachelor) S2 (Master) S3 (Doctor) ……Teachers …..Teachers .….Teachers ……Teachers TEACHER’S EDUCATION (Pendidikan Guru) Teachers College Graduate Non Teachers College Graduate (Sarjana lulusan Pendidikan) ................ (Sarjana lulusan Non Pendidikan) ..................... STATUS (Choose one) National School International School National Plus School MEMBERSHIP SOUGHT International Membership (Keanggotaan yang Diinginkan) National Membership
NAME ADDRESS FORMAL LEGAL ENTITY (Badan Hukum Formal)
PHONE FAX EMAIL NAME ADDRESS
SUPPORTING CHURCH (Gereja Yang Menaungi)
PHONE FAX EMAIL NAME ADDRESS
SUPPORTING INDIVIDUAL (OWNER) (Individu Yang Menaungi)
PHONE FAX EMAIL
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Membership Fee (Per Campus System) NATIONAL Membership fee PER CAMPUS FOR 1 YEAR FOR 2 YEAR Students 0-75
76-799
800 or more
Average Monthly Tuition*
Membership Fee
Membership Fee
All Levels
Rp. 450.000
N/A
< Rp. 200.000
Rp. 5.000 x _____ students
Rp. 9.000 x _____ students
Rp. 200.000 – Rp. 500.000
Rp. 6.000 x _____ students
Rp. 11.000 x ____ students
> Rp. 500.000
Rp. 7.000 x _____ students
Rp. 13.000 x ____ students
< Rp. 200.000
Rp. 4.000.000
Rp. 7.200.000
Rp. 200.000 – Rp. 500.000
Rp. 4.800.000
Rp. 8.640.000
> Rp. 500.000
Rp. 5.600.000
Rp. 10.080.000
TOTAL: Rp. ______________
INTERNATIONAL Membership fee PER CAMPUS FOR 1 YEAR 0-25
Minimum $ 261.00
26-724
$10.45x
725 or More
Maximum $ 7.576.00
_______
TOTAL : $ ___________
Rp. ______________
* Average Monthly Tuition is tuition per month, and is not a special rate or scholarship rate (Average Monthly Tuition adalah uang sekolah per bulan, yang adalah bukan rate khusus atau beasiswa)
Ministries Gift Accept
Decline
Your school is part of an extended international family of Christian educators and schools-bringing hope to children and families in 2,100 Christian schools in 105 countries worldwide. Your international colleagues make up the”1” in ACSI and are equipped and strengthened by your prayerful support. Your school can become a Global Friend by contributing or more to this life-changing work at the time you submit your membership fee. Many of the schools and educators that make up our international ACSI family cannot afford the essential prfessional development and school improvement resources they need to effectively achieve their Christ-centered mission. Truly, your generous support gives hope to children-for today and for eternity! Sekolah Anda adalah bagian dari keluarga besar pendidik-pendidik Kristen internasional dan sekolah-sekolah yang memberikan harapan bagi anak-anak dan keluarga-keluarga dalam 2.100 Sekolah Kristen di 105 negara yang ada di seluruh dunia. Rekan-rekan internasional Anda menjadi ”1” di ACSI dan diperlengkapi serta dikuatkan oleh dukungan-dukungan doa Anda. Sekolah Anda bisa menjadi Teman Global dengan ikut berperan serta atau bahkan lebih dalam suatu pekerjaan yang mengubah hidup ketika Anda menyerahkan iuran keanggotaan Anda. Banyak dari sekolah-sekolah dan pendidik-pendidik yang menjadi keluarga internasional ACSI tidak mampu mengupayakan pengembangan professional dan sumber daya-sumber daya pendukung pengembangan sekolah yang mereka butuhkan untuk mencapai misi mereka yang terpusat pada Kristus. Sejujurnya, dukungan tulus Anda memberikan harapan bagi anak-anak-sekarang dan di masa yang akan datang!
Membership fee for school in need
(Biaya partisipasi keanggotaan bagi sekolah yang membutuhkan) SELC participant fee (Biaya partisipasi SELC)
CEC-M.Ed participant fee (Biaya partisipasi CEC-M.Ed) ODE-CEDP participant fee (Biaya partisipasi seminar ODE-CEDP)
Membership Fee Worksheet (1) Membership Fee Sub total Rp._________________ (2) Ministries Gift Sub total Total Payment
Rp. _________________ Rp. _________________
Membership Fee Payment For National Membership Fee Please transfer / deposit to: Bank Danamon cabang Klampis Surabaya Acc. # 358-1079-823 a/n Perkumpulan Asa Cemerlang Sekolah Indonesia
For International Membership Fee Please transfer / deposit to: Bank Danamon cabang Klampis Surabaya Acc. # 358-1079-625 a/n Perkumpulan Asa Cemerlang Sekolah Indonesia
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ACSI-Indonesia Membership Terms & Condition 1. Fill up the ACSI-Indonesia membership application form completely. Mengisi formulir aplikasi keanggotaan ACSI-Indonesia dengan lengkap dan jelas. 2. Fully accept ACSI Statement of Faith as follows: Menerima Pengakuan Iman ACSI sebagai berikut: A. We believe the Bible to be the inspired, the only infallible, authoritative, inerrant Word of God (II Timothy 3:15-16, II Peter 1:21). Kami percaya kepada Alkitab sebagai Firman Allah yang diilhamkan , satu-satunya yang tidak dapat salah, yang berotoritas, dan yang sempurna (2 Timotius 3:15-16; 2 Petrus 1:21). B. We believe there is one God, eternally existent in three persons -- Father, Son and Holy Spirit (Genesis 1:1, Matthew 28:19, John 10:30). Kami percaya kepada satu Allah yang secara kekal keberadaanNya dalam tiga pribadi – Bapa, Anak, dan Roh Kudus. (Kejadian 1:1; Matius 28:19; Yohanes 10:30). C. We believe in the deity of Christ (John 10:33), Kami percaya kepada keilahian Kristus (Yohanes 10:33); His virgin birth (Isaiah 7:14, Matthew 1:23, Luke 1:5), Kelahiran-Nya dari seorang anak dara (Yesaya 7:14; Matius 1:23; Lukas 1:35); His sinless life (Hebrews 4: 15, 7:26), His miracles (John 2:11), kehidupan-Nya yang tanpa dosa (Ibrani 4:15,7:26); mujizat-mujizatNya (Yohanes 2:11); His vicarious and atoning death (I Corinthians 15:3, Ephesians 1:7, Hebrews 2:9), kematian-Nya yang menebus dosa dan mewakili umat manusia (1 Korintus 15:3; Efesus 1:7; Ibrani 2:9); His Resurrection (John 11:25, I Corinthians 15:4), kebangkitan-Nya (Yohanes 11:25; 1 Korintus 15:4); His Ascension to the right hand of the Father (Mark 16:19), kenaikan-Nya ke sebelah kanan Bapa di sorga (Markus 16:19); dan His personal return in power and glory (Acts 1:11, Revelation 19: 11). kedatangan-Nya kembali dalam kuasa dan kemuliaan (Kisah Rasul 1:11; Wahyu 19:11) D. We believe in the absolute necessity of regeneration by the Holy Spirit for salvation because of the exceeding sinfulness of human nature and that men are justified on the single ground of faith in the shed blood of Christ and that only by God's grace and through faith alone are we saved (John 3:16-19, 5:24, Romans 3:23, 5:8-9, Ephesians 2:8-10, Titus 3:5). Kami percaya kepada kepentingan secara mutlak akan kelahiran kembali oleh Roh Kudus bagi keselamatan karena sifat manusia yang penuh dosa; dan bahwa manusia dibenarkan hanya berdasarkan iman kepada darah Kristus yang tercurah; dan hanya atas karunia Allah dan melalui iman saja kita diselamatkan (Yohanes 3:16-19, 5:24; Roma 3:23, 5:8-9; Efesus 2:8-10; Titus 3:5). E. We believe in the resurrection of both the saved and the lost; they that are saved unto the resurrection of life, and they that are lost unto the resurrection of damnation (John 5:28-29). Kami percaya kepada kebangkitan orang yang percaya dan juga orang yang sesat; mereka yang percaya dibangkitkan ke dalam kehidupan kekal, dan mereka yang sesat dibangkitkan ke dalam penghukuman (Yohanes 5:28-29). F. We believe in the spiritual unity of believers in our Lord Jesus Christ (Romans 8:9, I Corinthians 12:12-13, Galatians 3:26-28). Kami percaya kepada kesatuan rohani semua orang percaya di dalam Tuhan Yesus Kristus (Roma 8:9; 1 Korintus 12:12-13; Galatia 3:26-28). G. We believe in the present ministry of the Holy Spirit by whose indwelling the Christian is enabled to live a godly life (Romans 8:13-14, I Corinthians 3:16, 6:19-20, Ephesians 4:30, 5:18). Kami percaya kepada kehadiran Roh Kudus, yang memampukan setiap orang Kristen--di mana Roh Kudus diam di dalamnya—untuk hidup suci (Roma 8:13-14; 1 Korintus 3:16, 6:19-20; Efesus 4:30, 5:18).
3. Own a leadership (Board members, Director, Principal, and Vice principal) that consists of born-again Christians and commits to provide Christian Teachers. Memiliki kepemimpinan (anggota Yayasan, Direktur, Kepala Sekolah, dan Wakil Kepala Sekolah) yang terdiri dari orang-orang Kristen yang sudah dilahirkan kembali, dan berkomitmen untuk menyediakan Guru-guru Kristen. 4. Non-discrimination policy in terms of gender, ethnicity, nationality, age, and special people. Tidak melakukan diskriminasi baik berdasarkan jenis kelamin, suku, kewarganegaraan, umur, maupun cacat tubuh. 5. To be printed in ACSI Membership Directory, membership registration should be completed. Agar tercetak dalam ACSI Membership Directory, pendaftaran membership harus dilakukan. 6. Transfers / deposits the Annual Membership Fee into ACSI Indonesia’s bank account. Mentransfer / menyetor Biaya Keanggotaan Tahunan ke rekening bank ACSI Indonesia
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Preferable of schedule ACSI Indonesia visit to your school (Jadwal yang dikehendaki untuk tanggal kunjungan ACSI Indonesia ke Sekolah Anda) Please list your school’s needs based on priority (Daftarkan kebutuhan Sekolah Anda menurut skala prioritas) 1. __________________________________________________________________________________________________________ 2. __________________________________________________________________________________________________________ 3. __________________________________________________________________________________________________________ Please list your school’s prayer items (Tuliskan pokok-pokok doa Sekolah Anda) 1. __________________________________________________________________________________________________________ 2. __________________________________________________________________________________________________________ 3. __________________________________________________________________________________________________________ Mode of receiving Newsletter (Penerimaan Nesletter dikehendaki secara)
Electronically, email address......................................................................... By mail/ courier
Signature Your signature affirms the following (Tanda tangan Anda menyatakan hal berikut): 1. We have read and agree with the ACSI Statement of Faith. Kami telah membaca dan menyetujui Pengakuan Iman ACSI. 2. We have read and agree with ACSI Indonesia Membership Terms and Condition. Kami telah membaca dan menyetujui Persyaratan Keanggotaan ACSI Indonesia. _____________________________________________________ Signature _____________________________________________________ Date _____________________________________________________ Name _____________________________________________________ Position Keep a copy of this application form for your records. Simpanlah salinan/fotokopi dari formulir aplikasi ini untuk arsip sekolah Anda.
We highly appreciate if the completed registration form including payment receipt is submitted before 31 Agustus 2015; and in return, we will give REACH Accreditation Manual 1.2. book (Kami akan sangat menghargai apabila Formulir lengkap beserta bukti pembayaran dapat diserahkan sebelum tanggal 31 Agustus 2015, dan sebagai ucapan terima kasih kami akan memberikan buku REACH Accreditation Manual 1.2. )
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