CORNERSTONE ADVENTIST ACADEMY

CORNERSTONE ADVENTIST ACADEMY
11431 University City Blvd, Charlotte, NC 28213 enrollment@cornerstoneadventistacademy.org
2026-2027 APPLICATION
Grade applying for
Date of application

MonthDayYear
Date
Gender
Full legal name of student

First NameMiddle InitialLast Name
Date of birth

MonthDayYear
Place of birth
Age
Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Format: (000) 000-0000.
Is this student a baptized member of the Adventist church?
If baptized, indicate year
Church where membership is held
Has applicant ever been suspended, expelled or asked to leave another school?
If yes, please explain.
"Revised Apr, 2026"
Page 1

FAMILY INFORMATION
Student living with
Other
Languages used at home
Father's name

First NameMiddle InitialLast Name
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Format: (000) 000-0000.
Work phone
Format: (000) 000-0000.
Cell phone
Format: (000) 000-0000.
Employer
Occupation
Is this parent a baptized member of the Adventist church?
Church membership held at
Mother's name

First NameMiddle InitialLast Name
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Format: (000) 000-0000.
Work phone
Format: (000) 000-0000.
Cell phone
Format: (000) 000-0000.
Employer
Occupation
Is this parent a baptized member of the Adventist church?
Church membership held at
Revised Apr, 2026
Page 2

EMERGENCY INFORMATION
Person to call if parent is not available
Relationship
Phone number
Format: (000) 000-0000.
Family physician or name of medical center used
REFERENCES
List the names and contact information of at least two people not related to the student who can speak to the student's character and academic readiness (i.e. teacher, Sabbath School teacher, Pathfinder counselor, etc.)
1. Name
Phone
Format: (000) 000-0000.
Email
example@example.com
2. Name
Phone
Format: (000) 000-0000.
Email
example@example.com
3. Name
Phone
Format: (000) 000-0000.
Email
example@example.com
4. Name
Phone
Format: (000) 000-0000.
Email
example@example.com
A $55 application fee is due along with this application. You may pay the application fee online via AdventistSchoolPay. If paying by check make payable to "Cornerstone Adventist Academy."
Revised Apr. 2026
Page 3

RECORD REQUEST FORM
Send Records to:
Cornerstone Adventist Academy
11431 University City Blvd
Charlotte, NC 28231
Name of Student
Grade
Date of Birth

MonthDayYear
Date
Request Documents from:
School
Street
City, State, Zip

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, as the parent of Child's Name , give permission to send all records (cumulative file with grade reports, health records, and any special testing) regarding my child to the requesting school.
Parent Signature
Date:

MonthDayYear
Date

11431 University City Blvd, Charlotte, NC 28213 · enrollment@cornerstoneadventistacademy.org
STUDENT RELEASE
Student Name
Grade
Date

MonthDayYear
Date
This form is good for one year from the date that it was filled out. You may add or delete from this list at any time with written notification to the school office.
The following individuals have my permission to pick up my child from school:
1.
2.
3.
4.
5.
6.
In the event that you need to send someone to pick up your child that is not on this list, please call the school office, your child's teacher, or the director of Extended Care with your request before your child is to be picked up. Please do not have someone call for you; we need to know that it is the parent/guardian
giving permission for this new arrangement.

Emergency phone numbers where parents can be reached:
1. Parent/Guardian Full Name Phone Number Phone Number
2. Parent/Guardian Full Name Phone Number Phone Number
Signature
Print Name

11431 University City Blvd, Charlotte, NC 28213 · enrollment@cornerstoneadventistacademy.org
2026-2027 CONSENT TO TREATMENT
This form must be filled out at the beginning of each school year to cover the activities for the school year. A copy of each student's form must be taken on off-campus activities.
Student's Name
Full Name
Age
Date of Birth

MonthDayYear
Address
Father/Guardian Name

First NameLast Name
Business Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Home Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Name

First NameLast Name
Business Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Home Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Any Allergies to Food and/or Medications
List Any Regular Medications
Date of Last Tetanus Shot
Family Physician
Office Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Preference
Please give the names of two relatives or friends who have consented to assume the responsibility of your son or daughter in case of illness or accident until you can be reached. In case of any changes in the named persons, notify the school in writing.
1. Name
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
2. Name
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
If emergency service involving medical action or treatment is required and neither the parent nor the family physician can be reached for consent, the parents hereby consent to the rendering of such emergency medical service for the above named student as shall be necessary in the medical opmion of the doctor rendering the service. This authorization is given pursuant to the local state Civil Code.
Signature
Date

MonthDayYear
Date

11431 University City Blvd, Charlotte, NC 28213 · enrollment@cornerstoneadventistacademy.org
2026-2027 MODEL RELEASE
Name of Student

First NameLast Name
For the consideration of allowing the minor child named above to participate in a Carolina Conference of Seventh-day Adventists (Conference) activity or use of its property, I irrevocably consent and give to the Conference, its employees, agents, servants, authorized representatives and officers, my authorization and permission to use any and all photographs of the minor child named above, of whom I am the parent/guardian, in which the minor child may be included in whole or in part, composite or retouched in character or form, without restriction for any purpose and without further compensation to me.

All negatives, positives, videotapes, audiotapes, electronic files, together with any prints, shall constitute, solely and completely, the property of the Conference for its use in advertisements, promotions, reports, websites or any other communications or documents. The Conference shall have the right to copyright the photograph or any document or product in which the photograph appears.
Signature
Date

MonthDayYear
Date
Name

First NameLast Name

11431 University City Blvd, Charlotte, NC 28213 · enrollment@cornerstoneadventistacademy.org
All parents and students must read the Handbook on the Cornerstone Website before school starts.
2026-2027 STUDENT PLEDGE
I pledge to abide by all guidelines as defined in CAA Handbook, and to honor Jesus in all I do. I will maintain a cooperative and willing spirit, treating the entire school community with respect. I will do my best to make positive contributions to the school program. Breaking this pledge jeopardizes my right to remain at Cornerstone Adventist Academy.
Signature
Date

MonthDayYear
Date
Name

First NameLast Name
2026-2027 PARENT PLEDGE
I agree to support the regulations and policies of CAA as listed in the CAA Handbook and announced by the administration during the year and willing to encourage my child to do so. I agree to assume the financial responsibility for the student, and pay bills promptly. I understand transcripts will not be released unless my child's account is paid in full.
Signature
Date

MonthDayYear
Date
Name

First NameLast Name
Should be Empty:

CORNERSTONE ADVENTIST ACADEMY

2026-2027 APPLICATION

FAMILY INFORMATION

EMERGENCY INFORMATION

REFERENCES

RECORD REQUEST FORM

STUDENT RELEASE

2026-2027 CONSENT TO TREATMENT

2026-2027 MODEL RELEASE

2026-2027 STUDENT PLEDGE

2026-2027 PARENT PLEDGE