KCA Application

KYIV CHRISTIAN ACADEMY

Enrollment Application
In order to apply for Kindergarten enrollment, children must be 5 years old before September 1st.

In order to apply for 1st Grade enrollment, children must be 6 years old before September 1st.
Application Date: *

Month Day Year
Date
What year are you applying for?
STUDENT INFORMATION:
Student's Name: *

First Name Last Name
Student's Preferred Name
Gender: *

Male Female
Date of Birth: *

Month Day Year
Date
For Which Grade Are You Applying: *
Student's Citizenship (example: USA) : *
Passport Copy: *

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Please provide a scanned copy of the students photo page of their current passport. If student does not have an international passport, please provide a copy of birth certificate. Cancel of
Is the student a NATIVE ENGLISH speaker? *

Yes No
Please list all other languages spoken by the student fluently:
What language does the family primarily speak in the home? *
Has the student been immunized? *

Yes No
If you answered "YES" to your student being immunized, please provide us a copy of your immunization record here:

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ADDRESS & CONTACT INFORMATION:
Address in Ukraine: *

Street Address

Street Address Line 2

City State / Province/Region

Postal / Zip Code
Student Phone Number: *
Student Email: *
example@example.com
PARENTAL INFORMATION:
Father's Name: *
Father's Email: *
example@example.com
Father's Phone Number: *
Father's Employer/Sending Agency: *
Mother's Name: *
Mother's Email:
example@example.com
Parent Phone Number: *
Mother's Employer/Sending Agency: *
EDUCATIONAL BACKGROUND:
School's Previously Attended: *
(please include NAME of school, LOCATION of school, DATES attended and GRADES attended). To add additional schools, click the "+" button.
Educational Transcripts:

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Please obtain a copy of your child's education transcript and upload it here. If the transcript is NOT in English, please have it officially translated and upload it with official translation. If your child has been homeschooled, please send a record of academic studies. This information is necessary in order for the KCA Administration to be able to make a final enrollment decision. Cancel of
LEARNING NEEDS:

Kyiv Christian Academy desires to accommodate the learning needs of its students and offers a limited variety of Supplemental Services. Please answer the following questions so that we may become aware of any potential learning needs.
Has the student had any scholastic difficulties in the past: *

Yes No
Does the student have any history of learning disabilities (i.e. dyslexia, dyscalculia, dysgraphia, etc.? *

Yes No
If you answered "YES" to the above, please provide more details including if you have an official diagnosis.
Does the student have any history of developmental disabilities such as autism spectrum disorder (ASD), cerebral palsy, Down syndrome, intellectual disability, etc.? *

Yes No
Has the student ever been enrolled in a special education program or supplemental services (i.e. pull out classes, resource room, speech therapy, occupational therapy or NILD? *

Yes No
If you answered "YES" to the above, please provide more details including which specific services were provided and whether or not any previous schools provided an IEP for your student.
Does the student have any history of social, emotional or behavioral disorders such as Attention Deficit/Hyperactivity Disorder (ADHD), conduct disorder, obsessive-compulsive disorder (OCD), anxiety, depression, etc.? *

Yes No
If you answered "YES" to the above, please provide us with more information.
Does the student take any medications for learning challenges or Attention Deficit/Hyperactivity Disorder? *

Yes No
If you answered "YES" to the above, please provide more details including which medication is taken and for what purpose.
SOCIAL INTERACTION BACKGROUND:
Hobbies, Interests & Skills: *
Please state your child's special interests, skills or hobbies.
Has the student had any disciplinary difficulties in the past: *

Yes No
Does the student have any physical, emotional, or other problems that may affect attendance or behavior? *

Yes No
BEHAVORIAL BACKGROUND:
Has the student ever been suspended, expelled or withdrawn from a school for any reason? *

Yes No
Has the student ever had any school conduct or disciplinary issues? *

Yes No
Has the student ever had any involvement with drugs, alcohol or vaping? *

Yes No
Has the student ever been brought before a Juvenile Court or law enforcement agency? *

Yes No
RELIGIOUS BACKGROUND:
Religious Background: *
If you answered "Other" above, please specify your beliefs:
If you answered "Christian" above, please tell us which denominational background:
Church or Place of Worship previously attended in HOME COUNTRY:
Church or Place of Worship attending in UKRAINE:
If you are a Missionary Family, which church or sending agency:
SIGN & SUBMIT:
Check the box if you agree: *

We affirm that the information contained in this document is true and complete. I understand that misrepresenting information could result in the refusal or dismissal of my child's enrollment at Kiev Christian Academy. Don't agree.
Check the box if you agree: *

By submitting this application to Kyiv Christian Academy, we recognize that KCA has the right to accept or deny our child's enrollment application. We also acknowledge that a non-refundable $50 application fee must be paid along wtih the submission of this application. Don't agree.
Father's Signature:

Clear
Mother's Signature:

Clear
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2021-2022 KCA APPLICATION FEE $ 50.00

Total $ 0.00
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KYIV CHRISTIAN ACADEMY

STUDENT INFORMATION:

ADDRESS & CONTACT INFORMATION:

PARENTAL INFORMATION:

EDUCATIONAL BACKGROUND:

LEARNING NEEDS:

SOCIAL INTERACTION BACKGROUND:

BEHAVORIAL BACKGROUND:

RELIGIOUS BACKGROUND:

SIGN & SUBMIT: