LCA Student Enrollment Form
2025-2026
Student Information:
Applying for Grade
*
Students Legal First & Last Name
*
Students Preferred Name, if different than legal name
Preferred Name
Middle Name
Last Name
Home Address
*
Date of Birth
*
/
Month
/
Day
Year
Date
Social Security #
*
Gender
*
Male
Female
Parent Information
Father's Name
*
Cell #
*
Email
*
example@example.com
Mother's Name
*
Cell #
*
Email
*
example@example.com
Does this student have any medical conditions?
*
Yes
No
If yes, please describe:
Emergency Contacts
Only parents/guardians listed above and individuals listed below may check out you child.
Contact #1 Name
*
Contact #1 Phone
*
Contact #1 Relationship to Child
*
Contact #2 Name
*
Contact #2 Phone
*
Contact #2 Relationship to Child
*
Contact #3 Name
Contact #3 Phone
Contact #3 Relationship to Child
Contact #4 Name
Contact #4 Phone
Contact #4 Relationship to Child
* Emergency contacts must be 18 or older and must provide ID when picking the child up.
School Information
Last School Attended
*
City
*
State
*
Has the student ever been enrolled in a Special Education/Resource/504/Gifted Program?
*
Yes
No
If yes, what type of program/services?
*
Where?
*
When?
*
Is this student currently under suspension/expulsion from another school?
*
Yes
No
If yes, what school?
*
Spiritual Information
What church does the child attend?
*
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