KCA Admissions Application

KYIV CHRISTIAN ACADEMY

Admissions Application
For the 2023-24 school year, KCA is launching our program for grades 1 to 6. Depending on interest and available teachers and resources, other grade levels will be considered as well.

In order to apply for Kindergarten enrollment, children must be 5 years old before September 1st.

In order to apply for 1st Grade enrollment, children must be 6 years old before September 1st.
Application Date*

MonthDayYear
What school year are you applying for?*
STUDENT INFORMATION
Student's Name*

First NameLast Name
Student's Preferred Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
For which grade are you applying?*
*contingent upon availability
Student's Citizenship*

USAUkraineKoreaOther
Passport Copy*

Please provide a scanned copy of the student's photo page of their current passport. If student does not have an international passport, please provide a copy of birth certificate.
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Is the student a NATIVE ENGLISH speaker?*

YesNo
Please list all other languages fluently spoken by the student
What language does the family primarily speak in the home?*
Has the student been immunized?*

YesNo
If you answered "YES" to your student being immunized, please provide us a copy of your immunization record here:

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ADDRESS & CONTACT INFORMATION
Home Address in Ukraine*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Phone Number*
Please enter a valid phone number.
Student's Email Address*
PARENTAL INFORMATION
Primary E-Mail Address for Family*
Which email address should we primarily contact?
Father's Name*

First NameLast Name
Father's Phone Number*
Please enter a valid phone number.
Father's Email Address*
Father's Employer / Sending Agency*
Mother's Name*

First NameLast Name
Mother's Phone Number*
Please enter a valid phone number.
Mother's Email Address*
Mother's Employer / Sending Agency*
EDUCATIONAL BACKGROUND
Student's Schools Previously Attended*
Please include NAME of school, LOCATION of school, DATES attended and GRADES attended.
Educational Transcripts

Please obtain a copy of your child's education transcript and upload it here. If the transcript is not in English, please have it officially translated and upload it with official translation. If your child has been homeschooled, please send a record of academic studies. This information is necessary in order for the KCA Administration to be able to make a final enrollment decision.
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LEARNING NEEDS

Kyiv Christian Academy desires to accommodate the learning needs of its students and offers a limited variety of Supplemental Services. Please answer the following questions so that we may become aware of any potential learning needs.
Has the student had any scholastic difficulties in the past?*

YesNo
Does the student have any history of learning disabilities (i.e. dyslexia, dyscalculia, dysgraphia, etc.?*

YesNo
If you answered "YES" to the above, please provide more details including if you have an official diagnosis.
Does the student have any history of developmental disabilities such as autism spectrum disorder (ASD), cerebral palsy, Down syndrome, intellectual disability, etc.?*

YesNo
Has the student ever been enrolled in a special education program or supplemental services (i.e. pull out classes, resource room, speech therapy, occupational therapy or NILD?*

YesNo
If you answered "YES" to the above, please provide more details including which specific services were provided and whether or not any previous schools provided an IEP for your student.
Does the student have any history of social, emotional or behavioral disorders such as Attention Deficit/Hyperactivity Disorder (ADHD), conduct disorder, obsessive-compulsive disorder (OCD), anxiety, depression, etc.?*

YesNo
If you answered "YES" to the above, please provide us with more information.
Does the student take any medications for learning challenges or Attention Deficit/Hyperactivity Disorder?*

YesNo
If you answered "YES" to the above, please provide more details including which medication is taken and for what purpose.
SOCIAL INTERACTION BACKGROUND
Student's Hobbies, Interests, & Skills*
Has the student had any disciplinary difficulties in the past?*

YesNo
Does the student have any physical, emotional, or other problems that may affect attendance or behavior?*

YesNo
BEHAVIORAL BACKGROUND
Has the student ever been suspended, expelled or withdrawn from a school for any reason?*

YesNo
Has the student ever had any school conduct or disciplinary issues?*

YesNo
Has the student ever had any involvement with drugs, alcohol or vaping?*

YesNoOther
Has the student ever been brought before a Juvenile Court or law enforcement agency?*

YesNo
RELIGIOUS BACKGROUND
Religious Background*
If you answered "Other" above, please specify your beliefs
If you answered "Christian" above, please tell us which denominational background
Church or Place of Worship previously attended in HOME COUNTRY
Church or Place of Worship attending in UKRAINE
If you are a Missionary Family, which church or sending agency
SIGN & SUBMIT
Select statement if you agree:*

We affirm that the information contained in this document is true and complete. I understand that misrepresenting information could result in the refusal or dismissal of my child's enrollment at Kyiv Christian Academy.Don't agree.
Select statement if you agree:*

By submitting this application to Kyiv Christian Academy, we recognize that KCA has the right to accept or deny our child's enrollment application. We also acknowledge that a non-refundable $25 application fee must be paid along with the submission of this application.Don't agree.
Father's Signature*

Clear
Mother's Signature*

Clear
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2023-24 Application Payment
$25.00

Total

$0.00
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KYIV CHRISTIAN ACADEMY

STUDENT INFORMATION

ADDRESS & CONTACT INFORMATION

PARENTAL INFORMATION

EDUCATIONAL BACKGROUND

LEARNING NEEDS

SOCIAL INTERACTION BACKGROUND

BEHAVIORAL BACKGROUND

RELIGIOUS BACKGROUND

SIGN & SUBMIT