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:
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:
Agreement & Signature
I agree and certify that:
Parent/Guardian Name:
Parent/Guardian Signature:
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.
Registration Fee for New Students (per student)

Early Registration (May)-$30 General Registration (June-July)-$60 Late Registration (August)-$90
Should be Empty:

Carolina Christian Academy Application

Parent/Guardian Information

Emergency Contact Information

Other Information

Agreement & Signature

Application Payment

Registration Fee for New Students (per student)