Student Application Online – Richlands Christian Academy

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Student's Name

First

Middle

Last

Student's Address

Street, City/State, Zip Code

Student's Telephone

Student's Age

Student's Sex

Male
Female

Student's Date of Birth

Student's Place of Birth

Student's Last Attended School

Addresss of Student's Last Attended School

Father's Name

First

Middle

Last

Father's Employment

If unemployed, enter "Unemployed". If employed, enter place of Employment.

Father's Employment Position

Father's Business Phone

Mother's Name

First

Middle

Last

Mother's Employment

If unemployed, enter "Unemployed". If employed, enter place of Employment.

Mother's Employment Position

Mother's Business Phone

Emergency Telephone Number

Parent's Marital Status

Married
Divorced
Widow(er)
Separated

Other Children in family of school age (If not applying)

List all other siblings of school age if they are not also applying to RCA

Reason Other Children in Family are Not Applying

Name of Church Currently Attending

Address of Church Currently Attending

Current Pastor's Name

First

Last

Church Telephone Number

Is Student's Father Christian?

Is Student's Mother Christian?

Has Student ever made a profession of faith in Christ?

Family Physician

First

Last

Physician Telephone Number

Business Status Christian?

Does Student have any physical challenges or allergies?

If yes, please explain:

Go into further detail on student's physical challenges or allergies

Has the Student ever been expelled, dismissed, suspended, or refused admission to another school?

If yes, please explain:

Provide further detail on the student's expulsion, dismissal, suspension or refused admission.

Has the Student ever had disciplinary difficulty at school?

If yes, please explain:

Provide further detail on the student's disciplinary difficulty.

Does the student have a juvenile or arrest record?

If yes, please explain:

Provide further detail on the student's juvenile or arrest record.

Has the Student ever used tobacco or nonprescription drugs of any kind?

If yes, please explain:

Provide further detail on the student's use of tobacco or nonprescription drugs.

Please indicate academic level of student's previous work:

Excellent
Good
Average
Poor

Has the Student ever failed an academic subject in school?

If yes, please explain:

Provide further detail on the student's failure of an academic subject.

How did you hear about this school?

Reason for selecting this school:

Parental Agreement

I agree to the following terms and conditions:

Application must be filled out completely before it can be processed.

An Application, Registration, and Testing fee of $BLANK must accompany Application and are not refundable. An interview with the parents and the student will be required before final acceptance.

Parental Agreement - Financial Obligation

I agree to the following terms and conditions:

For your convenience in meeting your financial obligations, tuition is divided into BLANK installments. The first payment is due on or before BLANK; the final payment is due on BLANK, before final progress reports are mailed at the end of the school year.

Parental Agreement & Permissions

I have read and agree to the following terms and conditions as well as giving my child permission for the relative areas:

"I hereby pledge to pay my financial obligations to the school on the date due and understand that it may be necessary to withdraw my student if proper arrangements are not made on a past due account."

"I give permission for my student to take part in all school activities, including sports and school-sponsored trips away from the school premises, and absolve the school from liability to me or my student because of any injury to my student at school or during any school activity."

"I agree to uphold and support the high academic standard of the school by providing a place at home for my student to study and giving my student encouragement in the completion of any homework or assignments."

"I appreciate the standards of the school and do not tolerate profanity, obscenity in word or action, dishonor to the Godhead and the Word of God, or disrespect to the personnel of the school. I hereby agree to support all regulations of the school in the applicant's behalf and authorize this school to employ discipline as it deems wise and expedient for the training of my student."

"I understand that the school reserves the right to dismiss any student who fails to comply with the established regulations and discipline or whose financial obligation remains unpaid."

"I have read the Student Handbook, agreed to complete Parent Orientation PACEs, and understand the terms stated on this Application and agree thereto."

Parental Electronic Signatures & Date

By checking this box, the parents of the students acknowledge the use of the electronic signature in submitting this application.

Enter the Father's & Mother's Name into the following box for Electronic Signature, as well as today's date.

Student Application - Online

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