NRCA Aftercare Application

NRCA Aftercare Application
School Year Applying for
Example: 2022/2023
GENERAL INFORMATION
Family Last Name
Email address to send application confirmation.
example@example.com

Children Enrolling
CHILDREN ENROLLING
1st Child's Name
First and Last Name
Grade
Birthday
XX-XX-XX
Allergies
Medication/Medical Needs
2nd Child's Name
First and Last Name
Grade
Birthday
XX-XX-XX
Allergies
Medication/Medical Needs
3rd Child's Name
First and Last Name
Grade
Birthday
XX-XX-XX
Allergies
Medication/Medical Needs
4th Child's Name
First and Last Name
Grade
Birthday
XX-XX-XX
Allergies
Medication/Medical Needs

Parent Contact Information
PARENT CONTACT INFORMATION
Father's Name
Father's Email
example@example.com
Father's Home Phone
Father's Cell Phone
Father's Address
City
State
Example: NC
Zip
Mother's Name
Mother's Email
example@example.com
Mother's Home Phone
Mother's Cell Phone
Mother's Address
City
State
Example: NC
Zip

Emergency Contacts & Authorized to Pick Up
EMERGENCY CONTACTS AUTHORIZED TO PICK UP:
Contact's Name #1
First and Last Name
Cell Phone
Relationship
Contact's Name # 2
First and Last Name
Cell Phone
Relationship
Contact's Name #3
First and Last Name
Cell Phone
Relationship
Contact's Name #4
First and Last Name
Cell Phone
Relationship
Contact's Name #5
First and Last Name
Cell Phone
Relationship
Contact's Name #6
First and Last Name
Cell Phone
Relationship

Bank Payment Information
Truist

Authorization Agreement for Automatic Debits (ACH Debits)
Parent Name*
First and Last Name
We (I) hereby authorize North Raleigh Christian Academy, hereinafter called COMPANY, to initiate debit entries to the account indicated below and the Bank named below, hereinafter called BANK, for the purpose of making Aftercare payments for my/our child/ren.

CHECKING ACCOUNT INFORMATION
Bank Name*
City*
State*
Transit/ABA No.*
Account No.*
This authorization is to remain in full force and effect until COMPANY has received written

notification from said parent of its termination in such time and in such a manner as to afford COMPANY and BANK a reasonable opportunity to act on it.
Provide Student's name(s) and grade(s)
Signature

Clear
Should be Empty: