Legacy Christian Academy - Student Application

General Information

First Name

Last Name

Preferred Name

Gender
Male
Female

Date of Birth

Street Address

City

State

Zip Code

School Last Attended (If Applicable)

Application Type
New Student
Sibling

Payment Plan
Full Payment
9 Month Plan

Name of Emergency Contact (Other Than Parent)

Emergency Contact Phone Number

Student's Doctor

Doctor's Phone

Parent/Guardian and Family Information

Father

Father's Full Name

Email Address

Street Address

City

State

Zip Code

Phone Number

Employer

Occupation

Highest Level of Education Completed

Mother

Mother's Full Name

Email Address

Same Address as Father
Yes
No

Street Address

City

State

Zip Code

Phone Number

Employer

Occupation

Highest Level of Education Completed

Household

Please list all people living in the student's household along with relationship to the student. (If student has more than one household, please include all.)

Mission Statement

To make disciples by coming alongside parents in teaching our students the Word of God; to prepare them academically and spiritually to go into the world and fulfill the Great Commission given by Jesus Christ.

I understand and the above Mission Statement of LCA.

Parent Questionnaire

How did you hear about LCA?

Considering the goals for your student, why would you like your student to attend LCA?

Has the student ever been referred to a resource teacher? If yes, please provide date and reasons for referral.

Has the student ever had modifications made in the classroom?

Has the student ever been administered psychological, behavioral, or academic testing to determine if he/she is gifted, has a learning disability, ADD, ADHD, behavioral, neurological, sensory, or emotional disorder?

Is the student presently taking any medications for medical or learning problems?

Does the student have any allergies? Please list all.

Does the student have any health problems?

Does the student have normal or corrected vision?

Does the student have normal hearing?

Has the student ever repeated a grade? If so, which grade? Please explain

Has the student ever been suspended or dismissed from school? If so, please explain.

Has the student ever had disciplinary difficulty in his/her previous school?

Is the student a ward of the court?

Is there any additional information that Legacy Christian Academy should be aware of when considering this student for enrollment?

Do you have a home church? If so, which one?

I certify that the above answers are true and made with no reservations:
Yes

Please type your name and date here.