Waco Christian Academy
Enrollment Form
Student Information
Name
*
First Name
Last Name
SSN
*
Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Please Select
Male
Female
Ethnicity
*
Please Select
African American
Hispanic/Latino
Asian
Caucasian
Native American/Alaskan
Hawaiian/Pacific Islander
Middle Eastern
Prefer not to answer
Other
Grade
*
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Are you Re-enrolling or is this your first time to Enroll at WCA?
*
Re-Enrollment
Enrollment
Current Residence Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Current Church Affiliation
Name of Church
*
Pastors Name
*
First Name
Last Name
Parent/Guardian Information and Resident Information(If different)
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
Emergency Contact 1
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Emergency Contact 2
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Physician and Medical Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Preferred Hospital
*
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
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Personal Reference 1
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Personal Reference 2
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Academic Reference
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
School Affiliation
*
Pastoral Reference
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Church Affiliation/Role
*
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Previous School
School Name
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date Started
*
-
Month
-
Day
Year
Date Picker Icon
Date Ended
*
-
Month
-
Day
Year
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Have you ever been expelled or asked to leave any previous school?
*
If yes, Explain why.
*
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
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