Office Use Only:
______Eng
_______ Links
Last Name _______________________________________
Check here if a new CCA student for 15-16 year ________
Chesterfield Christian Academy
______Gmail _______TCont
______QB
_______ Fees
2015-2016 Application/Course Request Form
Mail form to: Chesterfield Christian Academy, P.O. Box 1711, Midlothian, VA 23113
APPLICATION/REGISTRATION FEES AND TUITION: NO acceptance will be finalized until all forms and fees are received.
Application forms include: (1) Application/Course Request Form and (2) Spiritual Reference Form (grades K-5) or Spiritual
Testimony Form (grades 6 – 12). Upon acceptance, CCA will send a link to the (3) Handbook Signature Page and (4)
Emg/Medical Info form and they will be due before the first day of class.. Spiritual/Testimony forms can be found at
www.cca4u.org on the Registration page.
*All students registering for classes at CCA should have an approved Notice of Intent on file with their local school board.
Registration: Registration fees are $75.00 per student with a $210 maximum per family. Visit the website for discounted early registration fees. All
registration fees are non-refundable. *All payments are made directly to the Academy, payable to “CCA”.
**If you are in need of financial aid or are interested in monitoring a study hall, please see the “Tuition” page of our website and also submit the
necessary form.
__________ Initial
Breaks Between Classes: During any “breaks” between classes, students must be registered for a study hall. The tuition for each study hall is $100
per year. However, students are allowed ONE study hall hour between classes at HALF PRICE per week ($50/year). If your child has a break
between classes they are scheduled for, you must register and pay for a monitored study hall. This does include time a student is sitting and waiting
for a sibling. Study hall fees can be broken up into ten equal payments on the tuition contract.
__________Initial
Tuition: Tuition varies for each class. Tuition is paid monthly for a total of 10 months, beginning in August. Once the first payment is made, there is a
commitment for the full year’s tuition. See the handbook for more details. There is a $15.00 late fee for payments received after the 7th of each month.
Returned checks will be handled through a bank service and applicable fees from the bank will be charged in addition to the CCA late fee. Parents are
responsible to purchase textbooks and supplies for each class. Please see the handbook for available tuition discounts. Registration fees are due with
this application. SSNs are mandatory unless you are paying tuition in full by August 7th.
__________Initial
NOTE: NO REGISTRATIONS WILL BE ACCEPTED FROM CURRENT FAMILIES WHO ARE BEHIND IN PAYMENTS. 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 extended illness
and/or family relocation, the administration and teacher will consider excusing the student/family from their financial obligation. Other
situations will be considered individually to determine if there is just cause for releasing the family from their financial responsibility.
_________ Initial
Statement of Faith: ●We are a Christian homeschool co-op school that seeks 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.
_________ Initial
PARENT INFORMATION
Mom’s first name:
Last name:
SS#:
Dad’s first name:
Last name:
SS#:
Address:
City:
Home phone:
Primary email:
Mom’s cell:
Dad’s cell:
Zip:
Church Affiliation: __________________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Office Use Only: Amount
Date received
Check # _______
Cash
Administration initials
STUDENT INFORMATION AND COURSE REQUESTS (please list study halls needed) – Confirmation will be sent by
email
1ST Child: *Student’s first name:
Last name:
Date of Birth:
Age:
GRADE for 15/16 yearbook:
M F (circle one)
Class 1:
Day/Time:
Location: SS or Midlo
Class 2:
Day/Time:
Location: SS or Midlo
Class 3:
Day/Time:
Location: SS or Midlo
Class 4:
Day/Time:
Location: SS or Midlo
Class 5:
Day/Time:
Location: SS or Midlo
Class 6:
Day/Time:
Location: SS or Midlo
Study Hall Code(s) Needed:
2nd Child: *Student’s first name:
Date of Birth:
Last name:
Age:
GRADE for 15/16 yearbook:
M F (circle one)
Class 1:
Day/Time:
Location: SS or Midlo
Class 2:
Day/Time:
Location: SS or Midlo
Class 3:
Day/Time:
Location: SS or Midlo
Class 4:
Day/Time:
Location: SS or Midlo
Class 5:
Day/Time:
Location: SS or Midlo
Class 6:
Day/Time:
Location: SS or Midlo
Study Hall Code(s) Needed:
Please list any additional children and desired classes on a separate sheet of paper.
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 :
_________________________________________________________________________________________________
Learning Differences: If your child has any learning challenges or giftedness, note that CCA does not employ specifically
trained teachers. If this situation applies to one of your children, check here and we will email you our Learning
Differences Consultation Form to include with your other required paperwork. ______________
Computer access and a reliable internet connection are vital for success at CCA. CCA administration communicates
almost exclusively through email. Teachers utilize our online grading system, Engrade, for communicating with parents
and students as well.
________ Initials
*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. Additionally, school photos will be taken for CCA ID cards and
yearbook.
*By signing below, I acknowledge that submission of the Registration/Application Form does not guarantee admission and
that the Spiritual Reference Form 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
Date