MCA Application

Genesis Academy Application
By filling out this form you are beginning the first step of our application process. You will see below the additional requirements needed to complete the application and enrollment process.

Step 1: Submit application paperwork and fee:
- Application-the following paperwork is required to complete your application
  - Birth Certificate
  - Current GA Immunization Form #3231
  - Eye, Ear, Dental Form #3300
  - Transcripts
- $75 application fee
Step 2: Admission Screening/Testing

The applicant will participate in a screening and/or grade level test after all required paperwork has been submitted.

Step 3: Parent/Guardian and Student Interview

This meeting will be scheduled after all required paperwork and admission screenings/testing has been completed.

Educational Background
Does your child have a learning disability?
Has your child ever had, or currently have, an IEP?
Any psychological educational evaluations?
If yes, please submit a copy of all testing that has been done.
Upload files

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You may submit any psychological evaluations or IEP's here Cancelof
Has your child ever utilized the services of a counselor in a private practice, psychiatrist, or clinical psychologist?
List below your child's extracurricular interests, abilities (including musical instruments) and achievements:
Please explain why you would like your child to attend Genesis Academy

Parent Information
Mother/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone

Area CodePhone Number
Receive Text Messages?
Work Phone

Area CodePhone Number
Employer Name
Father/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone

Area CodePhone Number
Receive Text Messages?
Work Phone

Area CodePhone Number
Employer Name
Step-parent/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone

Area CodePhone Number
Receive Text Messages?
Work Phone

Area CodePhone Number
Employer Name
Custody Information
If either parent (or step-parent) is forbidden by court order from having access to the child or school records, please give that parent's name:
Name/See below to submit documentation
Upload documentation

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Any legal documents regarding guardianship, custody, etc. must be submitted to the school. Cancelof
Additional custody information:
Church Information
Church your family currently attends:
Pastor's name:
Church Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Describe your church attendance:
Father's testimony of faith:
Briefly describe how you became a Christian and your daily Christian experience.
Mother's testimony of faith:
Briefly describe how you became a Christian and your daily Christian experience.

Student Medical Release/Emergency Contacts
Upload birth certificate

Browse Files
May submit a hard copy Cancelof
Upload GA Immunization Form #3231

Browse Files
May submit a hard copy Cancelof
Upload GA Eye, Ear, and Dental Form #3300

Browse Files
May submit a hard copy Cancelof
Does your child have (or ever had) any medical conditions, allergies, etc.?
Please explain in detail.
Does your child take prescribed medication regularly?
If so, what medication?
If medication is to be taken at school, please provide any instructions on administering this medication.
Will your child require an epi-pen or asthma inhaler on-site?
If yes, please provide one to keep on-site at school.
Is Genesis Academy authorized to give OTC medications?
Check all that apply:

IbuprofenAcetaminophenTumsPepto Bismol

Emergency Contacts

List in order of preferred contact
Contact 1

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.
Add to approved pick-up list?
Contact 2

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.
Add to approved pick-up list?
Contact 3

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.
Add to approved pick-up list?
Contact 4

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.
Add to approved pick-up list?
Physician Information

In case of an emergency, we will provide this information to the hospital or physician on call.
Physician

First NameLast Name
Phone Number

Area CodePhone Number
Dentist

First NameLast Name
Phone Number

Area CodePhone Number
Parent/Guardian Release

As the parent/legal guardian of the above mentioned minor, I authorize representatives of Genesis Academy to administer the medication mentioned above. In the event I cannot be reached, I authorize a representative of Genesis Academy to consent to any x-ray examination, anesthetic, medical, dental, or surgical treatment which will aid the hospital and/or health care practitioner in making a diagnosis and providing emergency treatment for my child. I agree to be financially responsible for all costs and fees incurred in the emergency treatment provided to my child, including, but not limited to, emergency medical transportation deemed necessary by the attending staff, adult, paramedic, or healthcare practitioner. I understand that every reasonable effort will be made to contact me before these actions are taken.
Signature

Clear

Approved Pick-Up

Additional names for student pick-up
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation to student:
ex. father, mother, family friend, etc.

Student Record Release Authorization

Genesis Academy
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Previous School
Grade Last Attended
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
Parent/Guardian Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date

The above-named student has expressed an interest in attending Genesis Academy. Please submit the following items from their records:

Academic Records	Birth Certificate
Health Records	Social Security Card
Discipline Records	Achievement Test Scores/Summaries
Diagnostic Test Summaries	Psychological Evaluations
Recommendations for Remediation	Record of Remediation and Resulting Summary
Special Education/IEP Records

Please submit the requested records to Genesis Academy.

Address:

P.O. Box 877

Oakwood, GA 30566

Fax or email:

Fax: 770-531-9625

Email: info@gengrowth.org