MCA Application for Student Enrollment

10456 Old Carolina Rd, Midland, VA 22728

mcaoffice86@gmail.com

(540) 530-6530

3-Day Preschool (3 yrs) T, W, TH*

1/2 Day (9:00am-Noon)Full Day (9:00am-3:30pm)None

5-Day Preschool (3 yrs) M-F*

1/2 Day (9:00am-Noon)Full Day (9:00am-3:30)None

3- Day Pre-Kindergarten (4yrs) T, W, TH*

1/2 Day (9:00am-Noon)Full Day (9:00am-3:30pm)None

5- Day Pre-Kindergarten (4-5 yrs) M-F*

1/2 Day (9:00am-Noon)Full Day (9:00am-3:30pm)None

Kindergarten (Must be 5 yrs by Sept 30th)*

KindergartenNone

Elementary Grade*

Before School Care (7:00am-8:50am)

After School Care (3:30pm- 6:00pm)

Student's Full Legal Name*

Last

First

Middle

Nickname

Gender*

MaleFemale

Date of Birth*

Date

Age*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home phone

Work phone

Cell phone*

Email address*

example@example.com

Social Security #:

Occupation

Business

Title

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home phone

Work phone

Cell phone*

Email address*

example@example.com

Social Security #:

Occupation

Business

Title

Maternal Grandparents: Name, Mailing Address, Phone Number

Paternal Grandparents: Name, Mailing Address, Phone Number

Other children in family: Name, Age, School Attending

Name*

First NameLast Name

Phone*

Name*

First NameLast Name

Phone*

Name

First NameLast Name

Phone

School Name

Phone Number

Please enter a valid phone number.

School Name

Phone Number

Please enter a valid phone number.

Church Membership or Religious Preference

Please List Any Special Physical Conditions/Allergies We Should Be Aware Of: (Enter None, if needed) *

Medications Currently Taking: (Enter None, if needed)*

Physician/Clinic Name*

Phone Number*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Medical Insurance

Insurance Phone Number

Please enter a valid phone number.

Insurance Policy #

Insurance Group #

I, First Name* Last Name* hereby give permission that my child First Name* Last Name* may be given emergency treatment, to include first aid and CPR by qualified staff member of Midland Christian Academy. I further authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by my child's regular physician, or when that physician cannot be reached, by a licensed physician or hospital when deemed necessary or advisable by the physician to safeguard my child's health if I cannot be contacted. In such case, I waive my right of informed consent to such treatment. I also give permission for my child to be transported by ambulance to an emergency care center/hospital for treatment. I agree to accept all responsibility for the cost of any medical services.

ParentGuardian Signature*

Date*

Date

I Decline any imagery/filming of my child for advertising purposes.

Decline

Parent/Guardian Signature*

Date*

Date

Parent/Guardian Signature*

Date*

Date

By submitting a YES answer to this form, you consent to receive text messages from Midland Christian Academy regarding school closures, events, reminders, and important updates. Message frequency varies. Message and data rates may apply. You may opt out at any time by replying STOP or contacting the school office. (SEE Below for Terms & Conditions/Privacy Policy)*

Yes, I agree to receive SMS/MSS communication from MCANo, I do NOT consent.

Child's Birth Certificate

Child's Immunization records (All shots up-to-date)

Child's VA School Entrance Health Form (ONLY REQUIRED for Kindergarten/Elementary)

SMS Terms & Conditions

Product Description

By providing your mobile phone number, you consent to receive SMS messages from [Your Company Name] related to [describe the purpose, e.g., "order updates, promotional offers, or account notifications"].

Message Frequency (use whichever matches the submission in the registration form)

Message frequency may vary.
You may receive [X] SMS messages per [week/month].
Message and Data Rates

Standard message and data rates may apply.

Opting Out

You may opt out of receiving SMS messages at any time by replying with "STOP" to any SMS message you receive from us. After opting out, you will receive a confirmation message, and we will cease sending SMS messages to your number.

Help and Support

If you need assistance or have questions about our SMS service, reply with "HELP" to any SMS message you receive, or contact our customer support team at [support contact information].

Privacy Policy

Your phone number will be handled in accordance with our Privacy Policy, available at [link to Privacy Policy]. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Privacy Policy
Midland Christian Academy (MCA) respects your privacy. We collect personal information such as your name, email address, and phone number solely for school communication purposes. This includes updates, reminders, and alerts related to school events, closures, and programs.

Your personal information, including your mobile phone number, will never be shared, sold, or disclosed to third parties for marketing or promotional purposes.

You may opt out of receiving SMS messages at any time by replying STOP to any message or by contacting the school office directly.

For questions about this policy, please contact us at:
📞 540-530-6530
🌐 https://www.midlandchristianacademy.org

APPLICATION FOR STUDENT ENROLLMENT/RE-ENROLLMENT

Class Options:

Before & After School Care Options:

Student's Information

Parent/Guardian #1

Parent/Guardian #2

Other Than Parents, Child Will Only Be Released To Persons Indicated Below:

School(s) Last Attended

Student's Medical Information

Child's Physician/Clinic:

Consent to medical care/treatment of minor child

Advertising/Photo Release

I hereby authorize the use of my child's image for Midland Christian Academy's promotional purposes. I understand that such images may include any film media of my child engaged in school related activities on or off the school property.

Student Handbook

SMS/MMS Communication Consent:

MCA also requires copies of the following paperwork before a student can attend class: