Clone of Enrollment Form Free State Academy

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.Format: (000) 000-0000.

Secondary Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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*

Grade Level for 2026-27 academic year*

Student's Date of Birth*

Date

Second Student's Name

First NameLast Name

Gender

Grade Level for 2026-27 academic year

Student's Date of Birth

Date

Third Student's Name

First NameLast Name

Gender

Grade Level for 2026-27 academic year

Student's Date of Birth

Date

Fourth Student's Name

First NameLast Name

Gender

Grade Level for 2026-27 academic year

Student's Date of Birth

Date

Fifth Student's Name

First NameLast Name

Gender

Grade Level for 2026-27 academic year

Student's Date of Birth

Date

Name, address and phone number for previous school:*

Reason for leaving previous school*

Attendance Option*

Part-time Students: Which subjects, elective or clubs are you interested in?

How did you hear about FSA?*

Attach scanned copy of school transcript. An official transcript is required for high school credit.

Attach scanned copy of last grade report.

Enter any information about your child(ren)'s needs and family situations so we can better understand them. (IEP, 504, Diagnosis, Accommodations, Personality, Behavior, Family Dynamics, Authority, etc)*

Attach scanned copy of any additional documentation.

Is there a custody agreement in place or pending? If so, please provide a brief summary here and upload documentation below. An additional fee of $100 per day will be applied for court appearances (including documentation).*

Attach scanned copy of custody agreement.

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.) *

Which Church do you attend? How often do you attend? In what capacity do you serve at your church?*

Fundraising participation is a requirement to keep tuition as close to free as possible. Families may choose not to participate by paying the buyout fee of $50 per fundraiser.*

I understand that Free State Academy cannot succeed without active parent participation. Each parent is required to choose a responsibility in Sign-up Genius. Families may choose not to participate by paying the buyout fee of $50 per month.*

Click here for a list of the parental support roles:
https://www.signupgenius.com/go/10C0E4BA9AF28A3F4CF8-60586948-20262027
I have chosen the following parental support role:
blanks*

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*

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*

Cell Phones, Watches, Headphones and Computers
I understand that digital devices are not allowed at Free State Academy unless an exception is granted by the administration. Cell phones and earbuds will be locked up in the safe in the morning and returned at the end of the school day. Watches are to be used strictly for confirming the time. Computer usage requires advanced approval. I agree to abide by this policy and understand that detention or suspension are consquences for ignoring the policy. Please refer to the handbook for detailed information.

Signature confirming Cell Phones, Watches, Headphones and Computers*

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*

Academic Release
I understand that participation in Free State Academy involves personal and parental responsibility. I acknowledge that I am solely responsible for the well-being and education of my child.

I understand that Free State Academy is not accredited with the Virginia Department of Education. I will not hold FSA, its teachers, administration or volunteers responsible for standardized test scores or other related outcomes as I, the parent/guardian, am ultimately responsible for the material learned or not learned.

Signature confirming Academic Release*

Field Trip Permission
I grant permission for my child/ren to attend and participate in all Free State Academy field trips and activities. My child/ren have permission to ride in a car driven by a parent, volunteer, or staff member. I will not hold Free State Academy nor the parent, volunteer, or staff member liable for any mishaps and accidents. This permission is valid for the 2024-25 academic year unless I expressly state in writing that my child/ren is not able to participate or attend a specific field trip or activity. I will provide any changes in writing.

Signature for Field Trip Participation*

Field Trip Transportation*

Photo Release*

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*

IEP or 504 plan Policy
Free State Academy will do our best to honor and accommodate existing IEPs and 504 plans as we are able. FSA will not write any new IEPs nor 504 plans. I will inform the FSA leadership team of special circumstances, situations, or learning needs for my child/ren. FSA will maintain confidentiality for all students with learning or behavioral needs related to an IEP or 504 plan and will not share information outside the current administration and teaching staff.

I will not hold Free State Academy nor its administration, board members, teaching staff and volunteers responsible for related outcomes as I am responsible for the material learned or not learned. I will work closely with the FSA leadership team to ensure academic and social success for my child/ren. I also understand that my attendance with my child may become required. Children with special needs will be admitted on a case-by-case basis. A current copy of the IEP or 504 plan is required prior to enrollment confirmation.

Attach scanned copy of IEP or 504 plan.

Signature confirming IEP or 504 plan Policy*

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*

Annual full-time tuition is $3,500 per child enrolling any time prior to and during the first semester. Full-time tuition for mid-year enrollment any time during the second semester is $2000 per student.

Annual part-time tuition is $2000 per child enrolling any time prior to and during the first semester. Part-time tuition for mid-year enrollment any time during the second semester is $1200. Family purchases curriculum and supplies. Students must be at least 10 years old and may choose any three subjects, electives or clubs. This option does not apply to daily courses.

These tuition rates are for families who are actively involved in the success of Free State Academy through consistent participation in ALL fundraisers, activities, events, and parental support roles. ** Additional fees will be applied to tuition balance if family is not actively participating in FSA.

The $200 registration fee per child is due at the time of the enrollment. This is in addition to the annual tuition.

All tuition must be paid in full by the end of the academic year in May.

Tuition payment options:

A. Payment in full - due August 15th.

B. Monthly payments - amount will be determined by enrollment date.

C. Weekly payments - amount will be determined by enrollment date. Must be set up as a bank draft or automatic bill pay with documentation completed and submitted to FSA. Bank payments are mailed to Free State Academy 511 E Main St Bedford VA 24523

Scholarships may be available. If a scholarship is awarded, future tuition payments will be adjusted to reflect your award. When scholarships are awarded, recipient agrees to meet 990 hours of instruction and will take the CAT assessment at the end of the academic year. Recipient also agrees to keep tuition payments current. Failure to reach 990 hours of instruction, keep tuition current or failure to complete the CAT, will result in repayment of your scholarship award.

Withdrawals before August 1st, will receive a 100% refund of the amount paid minus the registration fee.

Withdrawals on or after August 1st, will not receive a refund for the amount paid and you are required to pay the remaining balance of tuition for the current
academic semester. Any scholarship must be paid back if the student withdraws.

Tuition Payment Choice*

Please enter your DISCOUNT CODE

I agree to the tuition and payment agreement set forth above. (My discount will be applied during my interview)

I understand that all tuition must be paid in full by the end of the academic year in May. I understand the refund policy as stated above. I understand that my scholarship award will need to be repaid if I withdraw. After August 1st, I understand that I am required to pay the remaining balance of tuition for the current semester.

I agree to actively participate in all fundraisers at FSA. If I choose not participate, I will pay the buyout fee of an additional $50 per fundraiser. This fee will be added to my tuition balance due.

I agree to actively participate in the functioning of FSA. I have chosen a parental support role in Sign-up Genius. If I choose not to actively participate and fulfill the role I selected, I agree to pay the buyout fee of $50 per month. This fee will be added to my tuition balance due.

Tuition, Scholarship, and Withdrawal Confirmation Signature *

Upload completed Scholarship application and tax documents in a zip file here. Both the scholarship application and income criteria can be found on our website https://www.freestateacademy.org/financial

This document shall remain in effect for the 2026-27 academic year and indicates my and/or my family’s participation in Free State Academy.

I agree to abide by the Statement of Faith regardless of my and my family’s personal beliefs. All members of my family will 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 leadership team 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.*

Comments

Date Document Signed*

Date

PAYMENTS: The registration fee ($200 per student) is due at the interview. Cash, check and credit card payments are accepted (with an additional prcoessing fee). Tution payments can be made in person or mailed to 511 E. Main St. Bedford, VA 24523

Free State Academy Enrollment Form