Registration Application

Registration Application

School Year 2024 - 2025
Main Street School, Inc. is a non-denominational Christian school that is committed to "Academic Excellence and Spiritual Vitality" through small classes and a faith-based curriculum.
Notice of Nondiscriminatry Policy

Main Street School, Inc admits students of any race, color, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.
Your family's church:
Your pastor's name:
How often do you attend church?
Please Note:

Registration is not complete until the registration fee has been paid.
Additional documents for registration of NEW students (returning students should already have these on file):
- Copy of Birth Certificate
- Current Immunization Record
- Virginia School Physical Form
- Any Standardized Testing Information, Grades From Previous Schools
After registration form is submitted online, please bring these documents to the school office.

New and Returning Students:

All immunizations must be up to date and the documentation must be on file in the school office. (These are the immunizations required for school entrance, not COVID-19 immunizations.)
Full Name*

First NameMiddle NameLast NameSuffix
1) Student Information
Birth Date *

MonthDayYear
Gender*
Select one
Ethnicity*
Select one
Student Cell Phone Number (If Applicable)
(Area Code)
Student Email Address (If Applicable)
example@example.com
Year Student Entered MSS*
(Returning students)
Previous Schools Attended
Grade anticipated for 2024-2025 School Year*
Select one

Additional Students:

If you are registering more than one student, please complete the additional fields for each student. If no additional students, please continue to the next page.
2) Student Information
Full Name

First NameMiddle NameLast NameSuffix
Birth Date

MonthDayYear
Date
Gender
Ethnicity
Student Email Address (If Applicable)
example@example.com
Student Cell Phone Number (If Applicable)
Area Code
Year Student Entered MSS
(Returning students)
Previous Schools Attended
Grade anticipated for 2024-2025 School Year
3) Student Information
Full Name

First NameMiddle NameLast NameSuffix
Birth Date

MonthDayYear
Date
Gender
Ethnicity
Student Email Address (If Applicable)
example@example.com
Student Cell Phone Number (If Applicable)
Year Student Entered MSS
(Returning students)
Previous Schools Attended
Grade for 2024-2025 School Year

Father's Name (or Legal Guardian)*

First NameLast Name
Parent Information
Father/Guardian Information
Father's Address (or Legal Guardian) (if different from child's address above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Phone Number (or Legal Guardian)
Please enter a valid phone number.
Father's Email Address (or Legal Guardian)
example@example.com
Father's Place of Employment (or Legal Guardian)
Father's Work Phone Number (or Legal Guardian)
Please enter a valid phone number.
Mother/Guardian Information
Mother's Name*

First NameLast Name
Mother's Address (or Legal Guardian) (if different from child's address above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Phone Number
Please enter a valid phone number.
Mother's Email Address
example@example.com
Mother's Place of Employment
Mother's Work Phone Number
Please enter a valid phone number.
Parent/Guardian Residence Information (if different from above)
Do both parents reside in the same home as the child?
Yes or no
Legal Guardian/Custody of Child (please provide all custody documentation):

FatherMotherBothOther (Grandparents, Aunt, Uncle, etc.)
If there is a custody agreement, please explain:

Emergency Contact Information
Emergency Contact 1
Name

First NameLast Name
Phone Number
(area code)
Relationship to Student
(Grandmother, uncle, etc.)
Emergency Contact 2
Name

First NameLast Name
Phone Number
(area code)
Relationship to Student
(Grandmother, uncle, etc.)
Emergency Contact 3
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Student
(Grandmother, uncle, etc.)
Physician and Medical Information
Health Insurance Provider
Name of Insured

First NameLast Name
Policy Number
Name of Pediatrician/Family Doctor
Phone Number of Pediatrician/Family Doctor
(Area Code)
Name of Dentist
Phone Number of Dentist
Please enter a valid phone number.
Preferred Hospital
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns, etc. If completing application for more than one child, please list the above information for each child, if applicable.
Please indicate student's name if more than one student on the application.
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.

Media Release

I grant permission for my child (children) to have his/her photograph and/or work published in various forms of media including but not limited to local newspapers, school newsletters, church newsletters, television clips, Facebook, and other forms of social media.
Signature

Clear
Registration & Curriculum Fee
You will receive an invoice for the registration and curriculum fees. Your child's registration is not completed until their fees are paid. Both are due before June 1. Please watch for your email for the invoice to come through.*

Registration ~ New/Returning Students $125.00 per childRegistration K4 $75.00 per childRegistration ~ Returning students (if paid by June 1) $75.00 per child
Curriculum Fees*

Curriculum Fee K-8th Grade $225.00 per childCurriculum Fee K4 $100.00 per child
Email for Invoicing Purposes:
example@example.com

Financial Responsibility
Please indicate the person financially responsible*
Payment in full for tuition may be made directly to the school office before the first day of school.

If a monthly tuition payment is desired, it is handled by Automatic Bank Payments or a Credit Card via a Tuition Agreement.

The Tuition Agreement must be made by August 1 as the Tuition Agreement draws payments on your set date from August - May.
Choose a Payment Option. A tuition agreement will be sent to you via email. The first payment on a tuition agreement is due in August.*
Terms of Agreement

I assume all financial responsibility for all tuition, fees and penalties assessed by Main Street School. I also understand registration fees are NON REFUNDABLE.
Signature*

Clear
Should be Empty:

Please Note: