UNITED CHRISTIAN ACADEMY

UNITED CHRISTIAN ACADEMY
Phone - 434-985-2947

225 Crusader Court P.O. Box 486 Stanardsville, VA 22973

Student Information:
First
Middle
Last
Grade to enter
Student's birthdate

MonthDayYear
Date
Sex

MaleFemale
Age as of August 1, 2024
Check here if Parent/Guardian information has been entered for a previous child

X
Parent/Guardian Information
First
Middle
Last
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Street address
City
State
Zip Code
2nd Parent/Guardian Information
First
Middle
Last
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
If different from above street address
City
State
Zip Code
Student's Religious Background
Current church attending
City/State
Church member?
Regularly attending?
Has student professed to have a personal relationship with Jesus Christ?
Parent/Guardian Religious Background
Check here if Parent/Guardian information has been entered for a previous child

X
Current church attending
City/state
Church member?
Regularly attending?
Have student's parents (either or both) professed to have a personal relationship with Jesus Christ?
Father's name
Phone
Employer
Occupation
Father's marital status (married, widowed, single, divorced)
Mother's name
Phone
Employer
Occupation
Mother's marital status (married, widowed, single, divorced)
If parents are unmarried, separated or divorced, who has custody of the child during the school year?
If parents have joint or primary/secondary custody describe the terms of the custodial arrangement and provide the address of the joint/secondary parent
**If a court has issued an order regarding child custody, parents must provide a copy of the order to the school.
Emergency Contact Information
Check here if Parent/Guardian information has been entered for a previous child

X
Primary emergency contact person
Relationship to student
Daytime phone
Secondary emergency contact person
Relationship to student
Daytime phone
Physician
Phone number
Medical conditions
Dentist
Phone Number
Please enter a valid phone number.
Type a Dental considerations (braces, brackets, etc child's medical conditions will be explained on the medical authorization & release form)
Student's Educational Background
Name and address of student's current school or the school student last attended
Administrators name
Dates Attended
School phone number
Do you as parent/guardian have reason to suspect a reading or learning disability in your child? If yes, please explain.
Has our child ever been diagnosed with special needs? If yes, please explain.
Has your child ever been recommended for, referred to, or received behavioral or psychological counseling? If yes, explain
Has the student ever been suspended from, expelled from, or asked not to return to school for any reason? If yes, explain
List any other factors in your childs life that would be helpful for the school to know absence or death of a parent traumatic incidents/accidents, etc
Attestation

I hereby attest that the foregoing information about myself, my family, and my child is correct and may be fully relied upon by the school to determine whether my child may be accepted to United Christian Academy. I understand that my child will not be enrolled at United Christian Academy until I have been notified of his/her acceptance in writing by United Christian Academy and have completed the enrollment agreement and enrollment forms.
Date

MonthDayYear
Date
Custodial Parent/Guardian Signature

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