VICTORY ACADEMY
2821 S. Wilmington St.
Raleigh, NC 27603
info@victoryacademyraleigh.com
www.victoryacademyraleigh.com
(984) 900-2830
Childcare application Form
Enter your admission information below. Please note, the application form and fee must be submitted for each child.
Child Name:
*
First Name
Middle Name
Last Name
Birth Date:
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
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2012
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1921
1920
Year
Child's Nickname:
Gender:
*
Male
Female
Child's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age at Entry:
*
Proposed Start Date:
*
-
Month
-
Day
Year
Date
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Family Information
Child Lives With:
*
Mother's Name:
*
First Name
Last Name
Mother's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Cell:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Email:
*
example@example.com
Mother's Employer:
Mother's Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Work Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Name:
*
First Name
Last Name
Father's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Cell:
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Email:
*
example@example.com
Father's Employer:
Father's Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Work Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Custody:
*
Mother
Father
Both
Other
Are there any custody arrangements that we need to be aware of?
Victory Academy will need to be provided with a copy of all custody paperwork.
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Contacts
Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals.
Contact 1 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact 2 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact 3 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Health Care Needs
For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan must be completed by the child’s parent or health care professional.
Is there a Medical action plan attached? (Medical action plan must be updated on an annual basis and when changes to the plan occur)
*
Yes
No
List any allergies and the symptoms and type of response required for allergic reactions.
*
List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns
*
List any particular fears or unique behavior characteristics the child has
*
List any types of medication taken for health care needs
Share any other information that has a direct bearing on assuring safe medical treatment for your child
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Emergency Medical Care Information
Name of Healthcare Professional
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Hospital Preference
Hospital Phone
Please enter a valid phone number.
Format: (000) 000-0000.
I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.
Today's Date
Today's Date
I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time custodian.
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Once application is submitted, you will be contacted to schedule an in-person interview.
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Registration Fee
Fees will be discussed in person based on level of care chosen and time of enrollment. Checks should be made payable to Victory Church. Checks should be mailed to: 2821 S Wilmington St. Raleigh, NC 27603, with your child's name in the memo section.
Payment Method:
*
Mail a Check
In-person at school
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