REGISTRATION FORM Today’s Date:__________ _________ Amount Enclosed _______
Student’s Full Name:__________ __________ __________ __________ __________ __________ _________
Birthday:__________ __________ __________ Age Now:__________ __Grade Entering:__________ _______ Social Security Number:__________ __________ ______ Home Phone Number:__________ __________ __
Mailing Address:__________ __________ __________ __________ __________ __________ __________ ___ City and Zip code:__________ __________ __________ __________ __________ __________ __________ __ Father’s Name:__________ __________ __________ __________ __________ __________ __________ ____
Mailing Address (if different from student):__________ __________ __________ __________ __________ ____
Home Phone #:__________ __________ __________ ____Cell Phone #:__________ __________ _________
E-mail address:__________ __________ __________ __________ __________ __________ __________ ____ Father’s Occupation:__________ __________ __________ __________ __________ __________ __________ _ Job location and phone number:__________ __________ __________ __________ __________ __________ _
Mother’s Name:__________ __________ __________ __________ __________ __________ __________ ____ Mailing Address (if different from student):__________ __________ __________ __________ __________ ____
Home Phone #:__________ __________ __________ __Cell Phone #:__________ __________ __________ __
E-mail address:__________ __________ __________ __________ __________ __________ __________ ____
Mother’s Occupation:__________ __________ __________ __________ __________ __________ _________ Job location and phone number:__________ __________ __________ __________ __________ __________ _
Please list the names and ages of other children in immediate family:__________ __________ __________ ___
__________ __________ __________ __________ __________ __________ __________ __________ _______
If an emergency: 1st choice person and # to call:__________ __________ __________ __________ _________
2nd choice:__________ __________ __________ ___ 3rd choice:__________ __________ __________ ______
Please list any diseases, allergies, or physical disabilities which we need to be aware of for this student:
__________ __________ __________ __________ __________ __________ __________ __________ _______ __________ __________ __________ __________ __________ __________ __________ __________ _______
Insurance policy number and company from which the student is covered:
I realize that I am expected to pay my fees on time.Payments are due by the 12th of each month, August –
I realize the school campus does not open until 8:00 A.M., and I should always check to make sure someone
I realize that if my child is disruptive in the classroom and/or if he or she will not obey, he or she will have his
I realize I must obey all Georgia Seat Belt rules on the WCCA campus.So, buckle up. We love our students.
I realize I can purchase Eagle Money (like a debit card) for my child to purchase lunches,
I give permission for my child’s photo to be on the school web site – however with no personal info other than name.
I should have my child’s health and academic records sent from their previous school to White Creek Christian Academy.
If during the school year any changes are made in any information given on this form, I should come by the office
I have read all the rules and regulations throughout the White Creek Christian Academy Website, and I promise to
Please return this Registration Form and the required Entrance/Book Use Fee to the following address or bring the form
Parent's Signature and Date:__________ __________ __________ __________ __________ __________ __
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