2022-2023 Registration

2022-2023 Registration
Student's Full Name *

First Name Middle Name Last Name Suffix
2022-2023 Grade Level *
Parent or Guardian *

Prefix First Name Last Name Suffix
Relationship to Student *
Primary Contact Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Contract

In signing this Application for Enrollment in Little Cypress Christian Academy (LCCA), I give LCCA permission for my child to take part in all school activities. I further agree to release and hold the school and its agents harmless from any liability to my child or any guardian or parent thereof because of any claims on behalf of my child against the school or any agent thereof because of any injury to my child. Should legal action be taken against Little Cypress Christian Academy or any employee or agent thereof, on my child’s behalf and the school or its agent not be found at fault, I agree to pay any attorney fees, court costs, damages or other cost that Little Cypress Christian Academy or its agent may incur defending itself against such action. I believe that discipline is necessary for the welfare of each student as well as for the entire school. I give my permission for my child’s teacher and/or administrator of the school to make and enforce classroom regulations understanding that LCCA does NOT administer corporal punishment. I agree to support the behavioral regulations enforced by the school.
Signature *

Clear

Parent Covenant

The Parent Covenant is intended to promote the fellowship of like-minded parents who seek to fulfill their obligation, in collaboration with Little Cypress Christian Academy faculty, to educate their child in accordance with our mission as a Christ-centered academic facility. To affirm and renew this agreement, we ask that all parents sign this covenant agreement each year and submit it with their re-enrollment contracts. While there are many aspects to being a parent of a Little Cypress Christian Academy student, the covenant agreement highlights six key areas: 1. We agree to pray for our child(ren) and school regularly, especially lifting up the teacher and his/her specific class in earnest prayer. 2. We agree to provide quiet time and a place for homework nightly. 3. We agree to volunteer when needed. 4. We agree to be responsible for all financial obligations to the school. 5. We agree to be supportive of Little Cypress Christian Academy and when speaking about the school and its students, always do so in a positive manner. 6. We agree to maintain communication with our child(ren)’s teacher(s), including checking assignment notebooks and/or folders. We acknowledge our awareness that failure to honor this covenant will result in an administrative conference to determine student’s eligibility to remain at Little Cypress Christian Academy. All students are enrolled on a tentative basis; Little Cypress Christian Academy Staff reserves the right to end enrollment if at any time we feel a student would benefit from a different learning environment.
Parent Signature *

Clear

Medical Insurance
Medical Insurance *

My child is NOT covered by medical insurance. My child is covered by medical insurance.
Name of Insurance Company *
Policy Number *
Insurance Company Phone Number *
I give staff at Little Cypress Christian Academy permission to seek medical attention for my child in the event of an injury while at school or school activities. *

Yes No

Student Allergy Management
Please list and explain any known allergies. *

Emergency Contact Information
In case of emergency, staff at LCCA will endeavor to call the student's parents or sole guardian. If you cannot be reached, we will contact the persons listed below if you give us you written permission.

If you cannot reach me/us by phone, you have my/our permission to contact the following persons, in the following order:
1. Name, Relationship, Phone Number *
2. Name, Relationship, Phone Number *
3. Name, Relationship, Phone Number *
4. Name, Relationship, Phone Number
5. Name, Relationship, Phone Number

Release to Photograph Student
I give permission for Little Cypress Christian Academy to photograph, video, or audio record my child. I also give permission to display my child's schoolwork including class pictures for educational purposes. *
I give permission for my child to use any technology sites or tools at Little Cypress Christian Academy with adult supervision. *

Physical Education Release
I understand the risks inherent in the participating in any physical activity. I am willing to assume this risk and here so by give consent for my child to participate in physical education activities at Little Cypress Christian Academy. I agree that LCCA along with its employees employees, agents, officers, and directors shall not be liable for any loses or damages occurring as a result of my child's participation in physical activities. *
My child is physically able to participate in physical education class at LCCA. *
Please let us know below if there is anything we should be aware of regarding your child's participation in Physical Education at LCCA. *

LCCA Recurring ACH Payment Authorization
I authorize regularly scheduled charges to my checking/savings account. I will be charged the amount indicated on monthly invoice each billing period. The charge will appear on your bank statement as an "ACH Debit". You agree that no prior-notification will be provided other than monthly invoice sent home with student. *
I authorize Little Cypress Christian Academy to charge my bank account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of US law. *
Account Type (checking or savings) *
Name on Account *
Bank Name *
Routing Number *
Account Number *
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Little Cypress Christian Academy in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACHdebits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transactiondates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Little Cypress Christian Academy may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form. *
Account Holder's Signature *

Clear

Tuition and Fees
I have read the 22-23 Handbook online and understand the financial obiligations associated with enrollment at LCCA. *

Yes
I understand that my child's enrollment is not secure until the registration fee has been paid. *

Yes
My Products *
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Registration Fee 1st Child
$ 350.00

Registration Fee Sibling
$ 50.00

Total

$ 0.00
Should be Empty:

2022-2023 Registration

Contract

Parent Covenant

Medical Insurance

Student Allergy Management

Emergency Contact Information

Release to Photograph Student

Physical Education Release

LCCA Recurring ACH Payment Authorization

Tuition and Fees