LPCA STUDENT ENROLLMENT APPLICATION FORM

STUDENT'S MEDICAL INFORMATION
STUDENT'S PHYSICIAN'S NAME

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does your student have allergies to foods or medications?
Please list all allergies and reactions. If no allergies, please type "N/A".
Please list any medications currently taking and their dosage. If not applicable, please type "N/A".
ACADEMIA
Has your student ever received IN SCHOOL or OUT OF SCHOOL SUSPENSION or ever been EXPELLED from any school attended? If so, please explain below. If not applicable, please type "N/A".
IF IN HIGH SCHOOL - STUDENT'S CURRENT GPA. (please type "N/A" if not applicable)
If student has taken Dual Enrollment classes previously, please list all schools below. (please type "N/A" if not applicable
If your student has previously taken the ACT, SAT, or other exam, please list exam taken, date taken, and scores received. (please type "N/A" if not applicable.)
If your student has been involved in Community Service Activities, please upload their service record.

Cancelof

FINALIZING APPLICATION
By signing below, I verify that the above items and all information provided on this application are true, complete and accurate. I consent to being contacted by the Administration of Lighthouse Private Christian Academy about the information I have provided. I agree to adhering to the mission and direction of Lighthouse Private Christian Academy and its administrative process.
By typing my name below, I confirm that the signature above is my signature and that this application has been completed by me with all accurate and true information.

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

LPCA STUDENT ENROLLMENT APPLICATION