Way of Jesus Academy Student Registration Form

Name of Father*

First NameMiddle NameLast Name
Living or Deceased*

LivingDeceased
Address (if different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone Number
Work Number
Please enter a valid phone number.
Cell Phone Number*

Name of Mother*

First NameMiddle NameLast Name
Living or Deceased*

LivingDeceased
Address (if different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Work Number
Please enter a valid phone number.

If child lives with someone other than parent(s) complete the following:
Name of Guardian
Relationship
Home Phone Number
Work Number
Please enter a valid phone number.
Cell Phone Number
Emergency Contact: (Please indicate someone other than parents/guardian)
Emergency Contact Name*

(First Name)(Full Middle Name)(Last Name)
Relationship to Student*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Telephone Number*

Previous Education
Has the student attended any United States schools including Puerto Rico at any time during his/her lifetime?

YesNo
Name of School
City & State
Grade Attended
Dates Attended
Name of School
City & State
Grade Attended
Dates Attended
Name of School
City & State
Grade Attended
Dates Attended

Medical Information
List any medical condition(s) your child has that we should know about (including allergies)
Family Doctor
Phone Number
Dentist
Phone Number

Please read the student handbook before filling out the following section.

Student Handbook
Parent/Guardian Statement of Understanding (Please initial each line)
1. We recognize that Way of Jesus Academy (WOJA) is a Christian ministry organization.*
2. We pledge our support of the school and its administration. We agree not to make demands, threaten to make any kind of accusation or complaint, or actually litigate any matter whatsoever.*
3. We have received the WOJA Student Handbook and have read and understood it in its entirety.*
4. We understand that our child will receive spiritual training and instruction consistent with the school and "Statement of Faith" which can be found in the Student Handbook.*
5. We agree that WOJA needs our participation in lending practical help and prayer support in a mutual effort our children.*
6. We understand that WOJA reserves the right to suspend or dismiss any student who does not cooperate educational process.*
7. We release WOJA from any responsibility for accidents that may occur on the school grounds or at school sponsored activities.*
8. We authorize the WOJA staff to relate with our child as described in the “Physical Contact and Restraint Policy” which can be found in the Student Handbook. .*
9. We permit WOJA to use any pictures of our child taken while at school or participating in an approved activity in any informational or promotional materials produced by the school, including, but not limited to, brochures, displays, and audio visual presentations.*
10. We hereby grant permissions for our child to attend and participate in all WOJA field trips. We will not hold or its employees responsible for injury to our child, or for loss, theft, or damage to his/her property while involved activities.*
Request for Textbooks & Materials (not to include K-4 students)
Pennsylvania provides textbooks and certain instructional materials to students in private schools. Parents, guardians, or persons in loco parentis shall request the loan of such materials by initialing the line below.
I hereby request the loan of instructional materials and textbooks in accordance with Act 90 of 1975 1972 for my child attending K-5 through 9th grade in Way of Jesus Academy. (Please initial)*
I certify that the foregoing statements made by me are true:
(Printed Name)*
(Signature)*

Clear
(Printed Name) 2nd Parent if available
(Signature)

Clear
Should be Empty:

Previous Education

Medical Information

Parent/Guardian Statement of Understanding (Please initial each line)

Request for Textbooks & Materials (not to include K-4 students)

I certify that the foregoing statements made by me are true: