RoxboroChristianAcademy
640Wesleyan Heights Road,POBox1357
Roxboro,NC27573
(336) 599-0208Fax#(336)599-0209
School Year: 20__ - 20__
ENROLLMENTAPPLICATION
Please provide the following information about your CHILD:Last Name: ______First Name: ______Middle Name: ______
SSN: ______Age: ______Sex: ______Applying to Grade: ______
DOB: ______Last School Attended: ______
Please sign here to give permission for us to obtain previous school records: ______
Does your child have any known physical, emotional or learning disabilities? ______
Please explain any scholastic/disciplinary difficulties:______
______
Other comments (if any): ______
______
Please provide the following information about YOURSELVES:
Parent 1: (I.E. Father, Mother, Step-Father, Step-Mother, Grandfather, Grandmother, etc.)
Relationship to child: ______
Last Name: ______First Name: ______Middle Name: ______
Street Address:______
City: ______State: ______Zip:______
Cell #: ______Home #: ______
Email Address: ______
Occupation: ______Employer: ______
Emp: Addr: ______
Emp: Phone: ______
What church do you attend? ______
What is your minister/pastor’s name: ______
Parent 2: (I.E. Father, Mother, Step-Father, Step-Mother, Grandfather, Grandmother, etc.)
Relationship to child: ______
Last Name: ______First Name: ______Middle Name: ______
Street Address:______
City: ______State: ______Zip:______
Cell #: ______Home #: ______
Email Address: ______
Occupation: ______Employer: ______
Emp: Addr: ______
Emp: Phone: ______
What church do you attend? ______
What is your minister/pastor’s name: ______
Please provide the following emergency contact information:
Primary Emergency Contact (other than Parent 1 or 2):
Last Name: ______First Name:______
Relationship to Student: ______
Home #: ______Cell #: ______
Work #: ______Email: ______
Secondary Emergency Contact (other than Parent 1 or 2):
Last Name: ______First Name:______
Relationship to Student: ______
Home #: ______Cell #: ______
Work #: ______Email: ______
Please provide the following medical information:
Primary Doctor: ______Primary Hospital: ______
Doctor’s Office Address: ______
Doctor’s Office Primary Number: ______
Please list all medications your child is currently taking:______
Is permission from a parent required before providing your child with either Ibuprofen or Tylenol?______
Permission for emergency treatment: I hereby give my consent for ______
to receive emergency medical treatment as may be considered necessary in the opinion of the attending licensed physician or paramedics: ______
Signature of Parent or Guardian
Please provide the following information about those authorized to pick-up your child in an emergency (other than yourselves)
Name:______Name: ______
Relationship to Child: ______Relationship to child: ______
Home #: ______Cell #: ______Home #: ______Cell #: ______’
Name:______Name: ______
Relationship to Child: ______Relationship to child: ______
Home #: ______Cell #: ______Home #: ______Cell #: ______’
Name:______Name: ______
Relationship to Child: ______Relationship to child: ______
Home #: ______Cell #: ______Home #: ______Cell #: ______’
IN MAKINGTHISAPPLICATION,IUNDERSTANDTHAT
1.Mychildhaspermissiontotakepartinallschoolactivities,includingsports,fieldtrips,etc.I willnot holdtheschoolliablebecauseofanyinjurytomychildatorduringschoolactivities.
2.TheschoolhasfulldiscretioninthedisciplineofmychildaccordingtoBiblicalprinciples(Proverbs 22:6, 15).Therefore,mychildmaybedisciplinedbytheprincipal,teacher,oranypersonwhois overthecareandwelfareofthechild. Note:Theschooldoesnotemploycorporalpunishment.
3.Theadministrationhasfullresponsibilityforplacingmychildacademically.Iwillensurethat mychildfulfillsallacademicrequirementsincludinghomeworkandthathe/shecooperatesfully withthestandards,policies,andregulationsoftheschool.
4.Mycooperationisexpectedin:(a)Promptpaymentoftuition;(b)Practicalhelp;(c)Faithful prayer;(d) AttendingPTFmeetings;and(e)Specialgiftssincetuitiondoesnotcovertheactual costsofeducatingmychild.
5.Theschoolreservestherighttodismissanystudentatanytimeforfailureinacademics, discipline,morality,orforanyattitudeorbehaviorthatisdetrimentaltotheschool.
6.Tuitionpaymentsaredueonthefirstdayofeachmonth(AugustthroughMay)andmustbe paidbythetenth(10th) ofthemonth.Afterthetenth (10th),theaccountbecomesdelinquentwithalatefeeof$25.00.Whenanaccountbecomes45daysinarrears,theparentwillberequestedtowithdraw thechildfromschooluntiltheaccountisnolongerpastdue.Ifachildattendsonedayofthemonth,theparentmustpaytheentiremonth’stuition.Monthlystatementswillbeprovidedbyemail around the first of the month.
7.IunderstandthatthefollowingstatementoffaithisthatofRoxboroChristianAcademy,andI submitthisapplicationfortheinstructionofmychildconsistentwithChristianprinciplesas revealedintheScripturesandconsistentwiththisstatementoffaith.
STATEMENTOFFAITH
WebelieveintheinspirationoftheBible(bothOldandNewTestaments);thecreationofmanby thedirectactofGod;theincarnationandvirginbirthofourLordandSavior,JesusChrist.We believeintheforgivenessofmankind’ssinbytheshedbloodofJesusChristandthecross. WealsobelieveintheresurrectionofHisbodyfromthetomb;thenewbirththroughregeneration bytheHolySpirit;andthegiftof eternallifebythe graceofGod.
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(Signatureof FatherorGuardian) (Date) (SignatureofMotherorGuardian) (Date)
Note:Bothparentsorguardiansmustsignthatyouacceptandagreewithitems1through7 above. Ifonlyoneparenthascustodyofthechild,thatonesignaturewillsuffice.Forachildto beofficially registered,a non-refundable fee of $135.00must accompany this application form.
Please see the tuition and fee schedule for a list of all tuition and fee due dates and charges!