Registration Form

Summer Child Care Registration
Guardian Names*

Primary GuardianSecondary Guardian
Primary Guardian Email *
example@example.com
Secondary Guardian Email
example@example.com
Primary Guardian Phone Number*
Please enter a valid phone number.
Secondary Guardian Phone Number
Please enter a valid phone number.
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact name and phone number*
First Student's Name *

First NameLast Name
Gender*
Student's Date of Birth*

MonthDayYear
Date
Second Student's Name

First NameLast Name
Gender
Student's Date of Birth

MonthDayYear
Date
Third Student's Name

First NameLast Name
Gender
Student's Date of Birth

MonthDayYear
Date
Fourth Student's Name

First NameLast Name
Gender
Student's Date of Birth

MonthDayYear
Date
Fifth Student's Name

First NameLast Name
Gender
Student's Date of Birth

MonthDayYear
Date
How did you hear about FSA?
Enter any information about your child(ren)'s needs and family situations so we can better understand them. (Diagnosis, Personality, Behavior, Family Dynamics, Authority, etc)*
Please explain any medical conditions in detail. Depending on the condition, FSA may require additional information and/or documentation. What medications will be provided for FSA to have on hand for your child? (epi pen, pain medication, allergy, etc.) *
Medical Release

I give permission to Free State Academy to attend to medical situations for my child/ren. My child is in good physical condition, except for listed restrictions or allergies listed above.

Should any illness or accident occur, I will not hold liable FSA adminstrators, volunteers, teaching staff or board members for medical aid rendered if any and I will fully reimburse medical or other expenses incurred in the care of my child/ren.

Free State Academy will with its best effort contact the responsible listed parent/guardian or emergency contacts. FSA will only carry out medical responsibilities if a parent/guardian or emergency contact cannot be reached in ample time.

My child/ren may receive first aid and medical attention by a duly licensed physician. My child/ren may be admitted to a hospital in case of emergency.
Signature confirming Medical Release*

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Personal Injury and Liability Waiver

I understand, by submitting this Release and Waiver of Liability to Free State Academy, also known as “FSA,” that our family is participating in activities at our own risk, and therefore release and forever discharge Free State Academy, the leadership individuals, and volunteers from any injury that I or my child/ren may suffer as a direct result of our participation in FSA. I knowingly and voluntarily enter into this agreement and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in FSA. I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against FSA for injury or property damage.
Signature confirming Personal Injury and Liability Waiver*

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Personal Responsibility For Property Damage
In the event that any property damage occurs to the belongings of our current building, a fellow student, volunteer, or staff member, as a result of my or my child/ren’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness.
Signature confirming Personal Responsibility For Property Damage*

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Damage/Loss Waiver
Free State Academy is not responsible for the damage or loss of personal items belonging to students, parents staff, or volunteers.
Signature confirming Damage/Loss Waiver*

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Photo Release*
FREE STATE ACADEMY STATEMENT OF FAITH

We believe The Holy Bible is the very Word of God in its entirety and is our only authority in matters of faith and practice.
• In the one and only God, our creator of the universe, who is eternally existing in the persons
of the Father, the Son, and the Holy Spirit.
• Jesus Christ was conceived by the Holy Spirit, born of the virgin Mary, crucified for our sins, and raised from the dead in eternal victory.
• Faith alone in Jesus Christ, the only Son of God, is the only way to eternal life.
• The Holy Spirit is a personal Being who convicts the world of sin and who regenerates, indwells, empowers, guides, and seals believers eternally for God.
• Heaven is the abode of God and the place of eternal joy for the saved, and that Hell is the
place of eternal punishment of separation from God for the lost.
• Marriage is God’s sacred gift and is to be between one man and one woman.
• Gender is God’s sacred design and is to be determined at conception, unchangeable by man.
• Human life begins at conception and is protected from conception to natural death.

I affirm that I have read, understood, and agree to respect FSA's Statement of Faith in my attitude, words, and conduct while I am affiliated with FSA.
Signature confirming FREE STATE ACADEMY STATEMENT OF FAITH*

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Free State Academy prefers not to collect vaccination records or birth certificates. Unfortunately, VDOE requires us to have these on file. Please upload a copy of your child/rens birth certificate and vaccination record or RELIGIOUS EXEMPTION form in one compressed (zip) file.

Cancelof
Registration:

The $35 registration fee is per child and due at the time of the enrollment. This fee can paid in person on your start date.

Child Care Tuition Rates:

A. Daily rate is $40 and payable at drop off.

B. Weekly rate is $125 and payable at drop off on Monday.

C. Monthly rate for 7:30-3pm is $300 and payable on the 1st of the month.

D. Monthly rate for 7:30-5:30 is $350 and payable on the 1st of the month.

Tuition payment options:

A. Daily, Weekly or Monthly payment options are available. Payment is required at the beginning of the reserved time. We accept cash, checks and credit card payments (with additional processing fee).

B. Payments can be dropped in the tuition box outside the school office or mailed to Free State Academy 511 E Main St Bedford VA 24523

If tuition is not paid in a timely fashion, children can not be dropped off for care.

Withdrawals & Refunds

A. Withdrawals must be in writing and the withdrawal form must be completed. As payment is scheduled for the time reserved, there are no refunds issued.
What attendance schedule will you need?
I agree to the tuition and payment agreement set forth above. I understand that all tuition must be paid as stated above. I understand the refund policy as stated above. *

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This document shall remain in effect June 2, 2025 through August 29, 2025.

I agree to abide by the Statement of Faith regardless personal beliefs. All members of my family agree to not promote an agenda contrary to the Statement of Faith.

If my behavior or conversations are contrary and interfere with the mission of FSA, I will be asked to meet with the administration and my enrollment can be terminated at any time for any reason. This release supercedes any and all previous oral or written promises or other agreements.
Signature confirming all information and documents submitted are true and accurate.*

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Date Document Signed*

MonthDayYear
Date
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Summer Child Care Registration