MCA Application

International Student 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.

1. Schedule a student interview

Contact Genesis Academy to make the appropriate arrangement for a student interview.

2. Complete Application Form and submit with the required documents and the $350 application fee (all forms must be translated into English)
- Application must include the following-Student/Parent Information, Student Connection, Teacher Recommendation, and Church Information
- Academic Transcripts-translated into English
- Current GA Immunization Form #3231
- Certified Copy of Official Birth Certificate
- Health, Medical, or Psychological Reports
- Copy of Passport and Visa
3. Parent/Guardian and Applicant Interview

Upon completion of the application you will then be scheduled for an interview with an Genesis Academy official. Genesis requires that the parent(s)/guardian(s) of the applicant and the applicant meet with the administration.

4. Acceptance

Upon completion of the application and interview process, you will be notified regarding the applicant's enrollment status. If applicant is accepted, the parent/guardian will meet with the finance office for payment arrangements and to complete and sign the enrollment contract. When this step is completed, the student's information will be submitted to SEVIS for processing.

Student Information

All information and documents must be in English.
The information must be filled out as requested and accurate as it is required for I20 application.
Student Legal Name*

Surname/Primary NameGiven NamePassport Name
Preferred Name*
Birth Date*

MonthDayYear
Gender*

malefemale
School year applying for:*
Grade*
Country of Birth*
City of Birth*
Country of Citizenship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student International Cell Phone
Student US Cell Phone
Student Email

Parent/Guardian Information
Mother/Guardian

Surname/Primary NameGiven Name
Email
example@example.com
Cell Phone

Area CodePhone Number
Father/Guardian

Surname/Primary NameGiven Name
Email
example@example.com
Cell Phone

Area CodePhone Number
US Guardian (host family information)*

Surname/Primary NameGiven 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?
Guardian

Surname/Primary NameGiven 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?
Student Residence
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
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

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