Date of Last Upload: Monday, May 15, 2023 Student Enrollment Form

New Student Information

Select the Submit Application tab after you have filled in all information including students, primary and secondary family, and emergency/contacts. Use the tab buttons to select the pages to fill in the information. * Required fields are bold.

Student's Information Primary Family Information Secondary Family Information Contact Information Submit Application

Student 1

*Last Name*First NameMiddle NamePreferred Name*Date of Birth (mm/dd/yyyy)SuffixTitleChurch AffiliationGenderRaceE-Mail*Grade LevelGrade CompletedStudent Health InformationCheck if any apply 1Check if any apply 2Check if any apply 3List any AllergiesOther AllergiesList any SurgeriesList other health info

Schools AttendedSchoolGradesCity StateDates Attended

With whom will this student reside?If the student does not reside with both father and mother, or if the student has been adopted, or is the subject of any court ordered relationship, please explain the child's legal status fully below. Please furnish a photocopy of adoption or other court order affecting the student.Student ResidesExplain legal status of child

Why do you wish to enroll your student in FCA?Why attend FCAWere you referred to FCA by someone?Referral

Student 2

*Last Name*First NameMiddle NamePreferred Name*Date of Birth (mm/dd/yyyy)SuffixTitleChurch AffiliationGenderRaceE-Mail*Grade LevelGrade CompletedStudent Health InformationCheck if any apply 1Check if any apply 2Check if any apply 3List any AllergiesOther AllergiesList any SurgeriesList other health info

Schools AttendedSchoolGradesCity StateDates Attended

With whom will this student reside?If the student does not reside with both father and mother, or if the student has been adopted, or is the subject of any court ordered relationship, please explain the child's legal status fully below. Please furnish a photocopy of adoption or other court order affecting the student.Student ResidesExplain legal status of child

Why do you wish to enroll your student in FCA?Why attend FCAWere you referred to FCA by someone?Referral

Student 3

*Last Name*First NameMiddle NamePreferred Name*Date of Birth (mm/dd/yyyy)SuffixTitleChurch AffiliationGenderRaceE-Mail*Grade LevelGrade CompletedStudent Health InformationCheck if any apply 1Check if any apply 2Check if any apply 3List any AllergiesOther AllergiesList any SurgeriesList other health info

Schools AttendedSchoolGradesCity StateDates Attended

With whom will this student reside?If the student does not reside with both father and mother, or if the student has been adopted, or is the subject of any court ordered relationship, please explain the child's legal status fully below. Please furnish a photocopy of adoption or other court order affecting the student.Student ResidesExplain legal status of child

Why do you wish to enroll your student in FCA?Why attend FCAWere you referred to FCA by someone?Referral

Student 4

*Last Name*First NameMiddle NamePreferred Name*Date of Birth (mm/dd/yyyy)SuffixTitleChurch AffiliationGenderRaceE-Mail*Grade LevelGrade CompletedStudent Health InformationCheck if any apply 1Check if any apply 2Check if any apply 3List any AllergiesOther AllergiesList any SurgeriesList other health info

Schools AttendedSchoolGradesCity StateDates Attended

With whom will this student reside?If the student does not reside with both father and mother, or if the student has been adopted, or is the subject of any court ordered relationship, please explain the child's legal status fully below. Please furnish a photocopy of adoption or other court order affecting the student.Student ResidesExplain legal status of child

Why do you wish to enroll your student in FCA?Why attend FCAWere you referred to FCA by someone?Referral

Student 5

*Last Name*First NameMiddle NamePreferred Name*Date of Birth (mm/dd/yyyy)SuffixTitleChurch AffiliationGenderRaceE-Mail*Grade LevelGrade CompletedStudent Health InformationCheck if any apply 1Check if any apply 2Check if any apply 3List any AllergiesOther AllergiesList any SurgeriesList other health info

Schools AttendedSchoolGradesCity StateDates Attended

With whom will this student reside?If the student does not reside with both father and mother, or if the student has been adopted, or is the subject of any court ordered relationship, please explain the child's legal status fully below. Please furnish a photocopy of adoption or other court order affecting the student.Student ResidesExplain legal status of child

Why do you wish to enroll your student in FCA?Why attend FCAWere you referred to FCA by someone?Referral

Primary Family Information

Address Line 1Address Line 2CityStateZIP CodeHome PhoneHome ListedCell PhoneCell Listed

Parent 1 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch AffiliationGenderRaceHome E-MailCell PhoneCell ListedCompany NameBusiness PhoneExtensionJob TitleIs Emergency ContactPickup LicenseBusiness E-MailIs Allowed to Pickup

Parent 2 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch AffiliationGenderRaceHome E-MailCell PhoneCell ListedCompany NameBusiness PhoneExtensionJob TitleIs Emergency ContactPickup LicenseBusiness E-MailIs Allowed to Pickup

Secondary Family Information

Address Line 1Address Line 2CityStateZIP CodeHome PhoneHome ListedCell PhoneCell Listed

Parent 3 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch AffiliationGenderRaceHome E-MailCell PhoneCell ListedCompany NameBusiness PhoneExtensionJob TitleIs Emergency ContactPickup LicenseBusiness E-MailIs Allowed to Pickup

Parent 4 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch AffiliationGenderRaceHome E-MailCell PhoneCell ListedCompany NameBusiness PhoneExtensionJob TitleIs Emergency ContactPickup LicenseBusiness E-MailIs Allowed to Pickup

Contact Information (Other than parents)

Contact 1

*Last Name*First NameRelationIs Emergency ContactHome PhoneIs Allowed to PickupBusiness PhonePickup LicenseCell PhonePickup TagPickup Notes

Contact 2

*Last Name*First NameRelationIs Emergency ContactHome PhoneIs Allowed to PickupBusiness PhonePickup LicenseCell PhonePickup TagPickup Notes

Contact 3

*Last Name*First NameRelationIs Emergency ContactHome PhoneIs Allowed to PickupBusiness PhonePickup LicenseCell PhonePickup TagPickup Notes

Medical Contacts

PhysicianPhysician Phone NumberDentistDentist Phone NumberHospitalHospital Phone NumberInsuranceInsurance Phone NumberPolicy Number

Finished

Confirmation E-Mail address:

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