LCA Application • Legacy House Church

Thank your for your interest in applying to Legacy Christian Academy!

Please ensure that all applicable fields are filled out completely to better

assist us in our review process. Thank you!

Student Information

First Name *

Last Name *

Middle Name

Age *

Date of Birth *

Gender

Students Social Security Number *

Tip: Numbers Only - Do not enter using dashes

Current Grade (Or grade going into) *

Home Address *

Home City *

Home State *

Home Zip Code *

Phone Number

Email Address

If different than above address.

Mailing Address

Mailing City

Mailing State

Mailing Zip Code

Last School Attended?

School *

Last Grade Completed *

School Address

City, State, Zip

Please explain reason for transfer and interest in LCA?

List any special interest of the student that would help us get to know them better.

Student Medical Information

Doctor Name *

Phone Number *

List any allergies or conditions, medical or non-medical.

Is the student currently taking any medications? *

Yes

Is the student up to date on all vaccinations? *

Yes

If yes please list any special instructions.

If yes please supply copy. If not please supply letter opting out.

Has applying student ever been tested for a reading or learning difficulty? *

Yes

If yes, please explain and include a copy of any available report.

Has the student been diagnosed with any behavioral or psychological disorders? *

Yes

If yes please explain.

Father

First & Last Name *

Address, City, St, Zip (If different than student address above)

Cell Phone *

Home Phone

Email *

Occupation

Work Phone

Employer

Mother

First & Last Name *

Address, City, St, Zip (If different than student address above)

Cell Phone *

Home Phone

Email *

Occupation

Work Phone

Employer

Biological Parents Marital Status *

Student Lives With *

Emergency Contacts

Other than Parents Listed Above

Name *

Relationship to Child *

Phone Number *

Permission to Pick Up Student from School? *

Name

Relationship to Child

Phone Number

Permission to Pick Up Student from School?

Name

Relationship to Child

Phone Number

Permission to Pick Up Student from School?

Does family attend church regularly? *

Does any family member serve actively in your home church? *

Name of home church (if applicable) *

Denomination *

We have read the Statement of Faith and understand that Biblical principles and values will be taught to my child at LCA of which we consent. *

Yes

Acknowledgment that physical Signatures will be required for Application and Enrollment packet upon acceptance. *

Yes

Student Information

Student Medical Information

Family Information

Father

Mother

Emergency Contacts

Faith Information