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Enrollment Application
To apply for enrollment, please fill out the information below.
Submit only one application per family.
Father First Name
Father Last Name
Phone
Primary Office Contact?
Yes
No
Address
Email
City
State
Zipcode
Marital Status
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Mother First Name
Mother Last Name
Phone
Primary Office Contact?
Yes
No
Mother Address (if different from Father's)
Email
City
State
Zipcode
Marital Status
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Is there a court order establishing custody rights?
Yes - please supply a copy
No
Do you plan to apply for Tuition Assistance?
Yes
No
Do you have internet access?
Yes
No
Church Family Attends
City
Where are you currently serving in your church?
Have you made a profession of faith in Jesus Christ?
Yes - Father
No - Father
Yes - Mother
No - Mother
If yes, please provide a brief testimony of your relationship with Jesus.
Approved Pick-Up People (other than parents)
People NOT authorized to pick up my child
How did you hear about LCA?
What interests you about your child attending LCA?
In what ways do you see yourself involved in the educational process?
Student Information
Student Name
Grade Entering
Birthday
Current Age
Gender
Male
Female
Social Security Number
Student's ethnic background
Hispanic/Latino
African American
Asian or Pacific Islander
Native American
Caucasian
Multi-Racial
Student lives with (check all that apply)
Father
Mother
Other
What languages other than English are spoken at home?
Previous School Name
Grades Attended
School Address
Has student ever been suspended, expelled, or denied admission to a school?
Yes
No
Has student ever repeated any grades?
Yes
No
Has the student ever received educational services/assistance or been seen by a learning specialist, school psychologist, or other mental health professional? Please check all that apply:
Been diagnosed with ADD, ADHD, dyslexia, etc.
Been tested and/or diagnosed as learning disabled
Been under medication which the school should be aware of
Has a current IEP (Individual Education Plan)
Physical Handicap or difficulties
Mental Health Services
None of the above
Medical Conditions
Food Allergies
Current Medications
Family Doctor and Phone Number
Preferred Hospital
Please list student's interests, hobbies, talents, and awards - in and out of school - related to academics, the arts, athletics, church, community service, clubs, and organizations
I grant LCA staff permission to obtain emergency care if warranted and will assume expenses for care.
Yes
No
Please list any additional students and their grades that you would like to be considered for enrollment:
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