School Enrollment Form

Welcome to Lux Christian Academy! We are thrilled to welcome you to the Lion family. Before you begin, please note that this application must be completed in one session, as it cannot be saved. If the session times out, you will need to restart the process. The form is designed to take approximately 15 minutes to complete. Please remember to submit one form per child. Thank you for choosing Lux Christian Academy!
Child Information
Child's First Name*
Child's Last Name*
Gender:*

MaleFemale
Date of Birth*

MonthDayYear
Date
Current Grade *
Home Addres
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Parent/Guardian/Authorized Representative
1st Parent/Guardian/Authorized Representative Name*
1st Parent/Guardian/Authorized Representative Name*
1st Parent Mobile Phone Number*
1st Parent Home Phone Number (if Different from child)
1st Parent Email Address*
example@example.com
1st Parent Business Phone Number*
2nd Parent/Guardian/Authorized Representative
2nd Parent/Guardian/Authorized Representative Name
2nd Parent/Guardian/Authorized Representative Name
2nd Parent/Guardian/Authorized Representative Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Parent Mobile Phone Number
2nd Parent Home Phone Number (if Different from child)
2nd Parent Email Address
example@example.com
2nd Parent Business Phone Number
Emergency Contacts/Authorized Pick Up
Names of additional persons in case emergency.
Emergency Contact Name*
Emergency Phone Number*
Emergency Contact- Relationship To Child*
2nd Emergency Contact Name
2nd Emergency Contact Phone Number
Emergency Contact- Relationship To Child
Physician & Dentist
Physician & Dentist to be called in Emergency & Medical Insurance Information
Please list any disabilities, medical conditions, or learning needs your child has*
Medical Insurance Company and Plan
Policy Number
Policy Expiration
Physician's Name
Physician's Name
Physician's Phone Number
Phone Number
Dentist's Name
Last Name
Dentist's Phone Number
Phone Number
List any allergies staff should be aware of
Does your child have any disabilities, physical limitations or needed adaptations? *
Does your child have any disabilities, physical limitations or needed adaptations? *
Does the child have any behavior concerns/fears/needs?*
Click here to read term and conditons.

Enrollment Fee

$475.00 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By signing, I confirm that I have read and agree to the terms and conditions linked above.*

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Date Signed *

MonthDayYear
Date
Physician & Dentist
Should be Empty:

Child Information

Home Addres

1st Parent/Guardian/Authorized Representative

2nd Parent/Guardian/Authorized Representative

Emergency Contacts/Authorized Pick Up

Physician & Dentist

Physician & Dentist