CCA Registration

Carolina Christian Academy Application
# of Children you are registering:*
Child #1 First & Last Name:*
Child's Age:*
Child's Date-of-Birth:*

MonthDayYear
Last School Grade Completed:*
Last School Attended:*
Please list any allergies, medical conditions, or physical disabilities:
Child's Physician*
Physician's Phone Number:*
Child #2 First & Last Name:*
Child's Age:*
Child's Date-of-Birth:*

MonthDayYear
Last School Grade Completed:*
Last School Attended:*
Please list any allergies, medical conditions, or physical disabilities:
Child's Physician*
Physician's Phone Number:*
Child #3 First & Last Name:*
Child's Age:*
Child's Date-of-Birth:*

MonthDayYear
Last School Grade Completed:*
Last School Attended:*
Please list any allergies, medical conditions, or physical disabilities:
Child's Physician*
Physician's Phone Number:*
Child #4 First & Last Name:*
Child's Age:*
Child's Date-of-Birth:*

MonthDayYear
Last School Grade Completed:*
Last School Attended:*
Please list any allergies, medical conditions, or physical disabilities:
Child's Physician*
Physician's Phone Number:*
Child #5 First & Last Name:*
Child's Age:*
Child's Date-of-Birth:*

MonthDayYear
Last School Grade Completed:*
Last School Attended:*
Please list any allergies, medical conditions, or physical disabilities:
Child's Physician*
Physician's Phone Number:*
Parent/Guardian Information
Father's Name:

First NameLast Name
Phone Number:
Mother's Name:

First NameLast Name
Phone Number:
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent's E-Mail:
Emergency Contact Information

Person to contact in case of an emergency (other than parents):
In Case of Emergency, Contact:*
Relationship to Child:*
Phone:*
Transportation Information

I authorize the following people to pick up my child:
Name:

First NameLast Name
Phone:
Name

First NameLast Name
Phone:
Other Information
How did you hear about us?*
Please Specify Other:
Church you currently attend:*
Document Upload
The following documents will be requested to complete acceptance into CCA. You may upload them now if you wish.
- Birth Certificate
- Immunization Record
- Social Security Card
- Prior School Record (if applicable)
Click upload to send file(s) electronically:

Upload File(s)

Cancelof
Agreement & Signature
Please review the following document:
I agree and certify that:*

The above information is accurate and correct to the best of my knowledge.I have read and agree to Carolina Christian Academy's Statement of Cooperation and Agreement.
Parent/Guardian Name:*
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Application Payment
Application Fee:
$30 per child
Transaction Fee:
Charged by the credit card processor in order to process the payment
Total:
Hidden - Used for calculation only. Total will show in payment.
Application fee waived for the month of May! Credit card information not required.

Total:

USD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Carolina Christian Academy Application

Parent/Guardian Information

Emergency Contact Information

Transportation Information

Other Information

Document Upload

Agreement & Signature

Application Payment

Application fee waived for the month of May! Credit card information not required.