Cumberledge Academy Enrollment Form (2025–2026)
Student Information:
Name
*
First Name
Last Name
Date
*
.
Month
.
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Name
*
First Name
Last Name
Relationship to Student:
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address (If different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Relationship to Student:
*
Phone Number
*
Please enter a valid phone number.
Medical Information
Allergies/Medical Conditions:
*
Primary Care Physician & Contact Info:
*
Tuition Package (Select One):
*
Premier Package – $8,000 (Full-Time) 1
Standard Package – $5,000 (Full-Time)
Core Package – $2,000 (Half Year / Part-Time)
Optional Add-Ons:
Laptop Rental – $300/year
Full Materials Kit – $500
Unlimited Field Trips – $500/year
Extra PE Support (Note: Inquire for reimbursement options)
Tuition Payment Schedule
Full-Time Enrollment (Premier & Standard Packages):
Tuition Due: August 1st (before school starts on August 19th). Optional Payment Plan: • First Payment: August 1st • Remaining: 1st of each month (August – May)
Part-Time Enrollment (Core Package):
Tuition Due: Two weeks before start date Fall Start: August 1st Mid-Year: Two weeks before agreed start date
Late Enrollment:
For enrollments after August 19th, tuition is due immediately upon confirmation. $50 penalty may apply for late payments. Payment plans must be arranged in advance.
Student Support Needs
If selected, Cumberledge Academy will provide a Student Support Plan (SSP) form to ensure appropriate accommodations.
I would like to request a Student Support Plan.
Acknowledgments (Be sure to read the handbook before, then please check all that apply:)
*
I have received, reviewed, and agree to abide by the Parent-Student Handbook.
I understand and accept tuition fees, payment terms, and refund policies.
I consent to my child participating in academy activities and field trips.
grant general permission for school-sponsored activities and understand separate slips may be required for off-campus events.
I acknowledge the attendance policy and agree to report absences within 24 hours.
I have reviewed and accept the Technology Usage Policy.
I agree to comply with all health and safety guidelines.
I understand failure to follow policies may result in disciplinary action or dismissal.
Consent for Media Release
*
I authorize Cumberledge Academy to use my child’s photo/video for educational or promotional purposes.
I do NOT authorize the use of my child’s photo/video.
Parent/Guardian Signature:
*
Date
*
.
Month
.
Day
Year
Date
Student signature (if age apropropriate)
Continue
Continue
Should be Empty: