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:__________ __________ __________ __________ __________ __________ __________ ____

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:

__________ __________ __________ __________ __________ __________ __________ __________ _______
Please list anyone who can pick up your child:

__________ __________ __________ __________ __________ __________ __________ __________ _______
Please list anyone who cannot pick up your child:

__________ __________ __________ __________ __________ __________ __________ __________ _______
Student’s Doctor, Dentist, Pastor and telephone number of each:

__________ __________ __________ __________ __________ __________ __________ __________ _______

Insurance policy number and company from which the student is covered:
__________ __________ __________ __________ __________ __________ __________ __________ _______

(continued)



If my child is hurt at school or on a school function and neither parent can be reached, I hereby
give WCCA officials permission to assume responsibility.  WCCA may choose the doctor and/or hospital
which they think necessary for the safety of my child.I realize that I am responsible for all
expenses which may result due to the injury.I realize that WCCA does not provide insurance benefits for students.

I realize that I am expected to pay my fees on time.Payments are due by the 12th of each month, August –
May.If I do not pay what is due by the 12th, I will be expected to pay the $25.00 late fee.I, also, realize that there
will be a $25.00 charge on any returned checks. And, if I get at least two months behind, I realize my child is subject
to dismissal. No records will be released until the account has been paid in full and the student’s books are
returned in good shape.

I realize the school campus does not open until 8:00 A.M., and I should always check to make sure someone
is on duty before I leave my child.School starts at 8:10. After school, I must pick-up my child within 30 minutes
of their last class bell.The pick-up time for pre-school is 11:40 and for K5 and up the latest pick-up time is 3:00 P.M.

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
teacher or principal to explain how he or she should act. If this does not help, we will call in the parents for a
conference.If the student does not improve immediately, he or she is subject to dismissal. 
WCCA does not administer corporal punishment.

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,
snacks, drinks, supplies, etc.  I will be notified by e-mail when my child is out of money and has charged to the office.

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 this is the first time for the student to be in a school, then all of the student’s health records showing immunization
is due on their first day of school.  This is a state-wide health rule.

If during the school year any changes are made in any information given on this form, I should come by the office
and up-date the student’s file.This is most important in case of an emergency situation.

I have read all the rules and regulations throughout the White Creek Christian Academy Website, and I promise to
see that my child and my family obey and respect all of the rules as outlined on the site or in the current Student Handbook.

Please return this Registration Form and the required Entrance/Book Use Fee to the following address or bring the form
and fee to the office: White Creek Christian Academy; 67 Academy Drive; Cleveland, Georgia 30528. 
Please feel free to call if you have any questions.Our phone number is 706-865-1917.

 Parent's Signature and Date:__________ __________ __________ __________ __________ __________ __