Chesterfield Christian Academy – Application/Registration Form
Mail form to: Chesterfield Christian Academy, P.O. Box 1711, Midlothian, VA 23113
PARENT INFORMATION
Mom’s first name:
Last name:
SS#:
Dad’s first name:
Last name:
SS#:
Address:
City:
Zip:
Home phone:
Primary email:
Mom’s cell:
Dad’s cell:
Church Affiliation: ____________________________________________________________________________________________
STUDENT INFORMATION AND CLASS ENROLLMENT INFORMATION
1ST Child:
*Student’s first name:
Date of Birth:
M F (circle one) Allergies and Medications:
Age:
Class 1:
Class 2:
Class 3:
Class 4:
Class 5:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Last name:
Grade for 09/10 school year:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
2nd Child:
*Student’s first name:
Date of Birth:
M F (circle one) Allergies and Medications:
Age:
Class 1:
Class 2:
Class 3:
Class 4:
Class 5:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Last name:
Grade for 09/10 school year:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
3rd Child:
*Student’s first name:
Date of Birth:
M F (circle one) Allergies and Medications:
Age:
Class 1:
Class 2:
Class 3:
Class 4:
Class 5:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Last name:
Grade for 09/10 school year:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
4th Child:
*Student’s first name:
Date of Birth:
M F (circle one) Allergies and Medications:
Age:
Class 1:
Class 2:
Class 3:
Class 4:
Class 5:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Day/Time:
Last name:
Grade for 09/10 school year:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
Tuition Fee:
STATEMENT OF FAITH
We are a Christian homeschool academy that seeks serve Christian families who have chosen to homeschool their children. Our goal is to put Christ
at the center of every subject, whether it is math, science, history, etc. and to present them from a Biblical worldview. It is our belief that the study of
these subjects should direct our students to our Creator and Heavenly Father.
 We believe the Bible is God’s Holy Word, without error, and is our final authority in all matters of faith and practice.
 We believe in one God existing as Father, Son and Holy Spirit.
 We believe Jesus is the Son of God.
 We believe Jesus Christ is both fully God and fully Man, conceived from the Holy Spirit and born of a virgin. He lived a sinless life,
performed miracles, died upon the cross and rose again, conquering sin and death.
 We believe in a literal 7-day creation as recorded in the book of Genesis. We believe in the young earth philosophy and do not support the
theory of evolution.
I believe and support the statement of Faith yes
no
If no, please explain:
REGISTRATION AND TUITION-All students registering for classes at CCA should be have an approved Notice of Intent on file with their local school
board.
Registration: Registration fees are $65.00 per student with a $195 maximum per family. If received by April 15, the registration fee is only $50.00
per student with a maximum of $150 per family. All registration fees are non-refundable. Registrations received after July 31st will be considered
for acceptance on an individual basis. *All payments are made directly to the Academy, payable to “CCA”.
Tuition: Tuition varies for each class. Tuition is paid monthly for a total of 10 months, beginning in August. There is a $15.00 late fee for payments
received after the 7th of each month and a $30.00 fee for any returned checks. Please see the handbook for available discounts. Registration fees are
due with this application.
NOTE: Annual class and financial commitments are made when the first tuition payment is received in August. Students and parents wishing them to withdraw from a
class anytime after the first payment is received will still be obligated for the full year's tuition. In certain circumstances, such as illness, family relocation, unexpected
financial hardship, and/or academic issues, the administration and teacher will consider excusing the student/family from their financial obligation. Each case will be
considered individually to determine if there is just cause for releasing the family from their financial responsibility.
PREVIOUS EDUCATION AFFILIATIONS
Please list any other previous schools or homeschool groups you’ve been involved with.
(A) School Name: __________________________________________ Child(ren) Attended: ________________________________
Contact Person:_______________________________________ Phone Number: _________________________________________
(B) School Name: __________________________________________ Child(ren) Attended: ________________________________
Contact Person:_______________________________________ Phone Number: _________________________________________
Has any member of your family ever been asked to leave or been expelled from any other school or homeschool group? If so, please
explain on a separate sheet. Please share with us the primary reason you have chosen to homeschool :
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
STUDENT EXPECTATIONS
Students are expected to conduct themselves in a godly manner. Students should exhibit the following:
*Respect for God
*Respect for Authority
*Respect for Others
*Respect for Self
*Respect for the Facility
The parents, as the primary teachers, will be expected to take the lead in the disciplining process. Parents will be notified and expected to endeavor
to correct the behavior, but if this doesn’t occur, CCA will determine whether or not a student will be permitted to stay. The following behaviors will
require discipline from one of the Directors:

Disrespect to staff member(s). The staff member(s) will determine when disrespect has been demonstrated.

Dishonesty. This includes, but is not limited to lying, cheating, and stealing.

Rebellion. This includes, but is not limited to outright disobedience to instruction.

Fighting. This includes, but is not limited to striking another person in anger with intent to harm.

Unkind, obscene, inappropriate, or profane language, including taking the Lord’s name in vain.
EMERGENCY INFORMATION AND PARENTAL RELEASE
Name of person to call in an emergency (other than parent):
Home phone:
Cell phone:
My child has permission to participate in homeschool classes with Chesterfield Christian Academy in Chesterfield, VA. If my child
should suffer an injury during classes, I understand that I will be contacted and will be responsible for any medical expenses that may
incur. I give the adult in charge permission to secure emergency medical treatment for my child if necessary.
*By signing below, I understand that I release Chesterfield Christian Academy, the instructors, and/ or the facility owner of any liability
and/or compensation for any bodily injury or damage/theft to personal property.
*By signing below, I give CCA permission to use photographs taken of my child/ren throughout the school year to be used in publications
related to Chesterfield Christian Academy.
*By signing below, I acknowledge that submission of the Registration/Application Form does not guarantee admission and that the Spiritual
Reference Form and signed Code of Conduct must also be completed. The Directors of CCA will determine the final decision for admission.
*I have read, understand, and agree to CCA’s policies, procedures, and statement of faith.
Parent SIGNATURE
Office Use Only: Amount
Date
Date received
Check # _______
Cash
Administration initials