Office Use Only:
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______Gmail _______TCont
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_______ Fees
Last Name _______________________________________
Chesterfield Christian Academy
NEW FAMILY APPLICATION 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 Form and (2) Tuition Agreement (3) Spiritual Reference Form (grades K-5) or
Spiritual Testimony Form (grades 6 – 12). Upon acceptance, CCA will send an (4) Admission Interview Time and link to the
(5) Handbook Signature Page and (6) Emg/Medical Info form and they will be due before student can attend class.
Spiritual/Testimony forms can be found at www.cca4u.org on the Registration page. These need to be brought to the
interview.
*All students applying for classes at CCA should have an approved Notice of Intent on file with their local school board.
APPLICANT(S) INFORMATION
Name of Student(S) :________________________________________________________ Grade:_______________
________________________________________________________ Grade:_______________
________________________________________________________ Grade:_______________
PARENT INFORMATION
Mom’s first name: ___________________________________ Last name: _____________________________________
Dad’s first name: ____________________________________ Last name: _____________________________________
Address:
City:
Home phone:
Primary email:
Mom’s cell:
Dad’s cell:
Zip:
Church Affiliation: __________________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Application: There is a one-time application fees of $20.00 per family. All application fees are non-refundable. *All payments are made directly to
the Academy, payable to “CCA”. Registration fees are listed on the attached registration page.
**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: CCA monitors students at all time while at CCA property. 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 and is charge as an annual fee, not a monthly charge. Tuition can be paid monthly for a total of 10 months,
beginning in August and payments are due the 7th of each month. 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 on the TUITION AGREEMENT unless you are paying tuition in full by August 7th.
__________Initial
Annual Commitments: CCA requires annual commitments to classes. All class changes and dropping of classes needs to be made by August 7 th.
After August 7th if a student is on a roster, parents are committed to pay the entire year’s tuition for that class. Please see the TUITION AGREEMENT
for details and any exclusions.
__________Initial
Engrade: 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
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
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. ______________
*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
Please include $20 Application Fee (registration fees are listed below on registration page)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Office Use Only: Amount
Date received
Check # _______
Cash
Administration initials
Chesterfield Christian Academy
First, Last Name:
Tuition Agreement 2016-2017
Street Address:
TERMS OF CONTRACT
City, State, Zip:


Tuition is calculated annually and divided into ten (10) equal monthly payments unless families choose to pay in full or by
semester.
Sibling discounts are offered as follows:

10% discount of the class tuition for the second child enrolled in the same class
Parent’s Initials

Withdrawal from Classes
Once the first payment is made, parent is responsible for the full tuition of the class. See Handbook for more details.
In the event that the child must be withdrawn from Chesterfield Christian Academy prior to the completion of the school term,
tuition will be due in full unless an exception is made and approved on by the Co-Directors.
Parent’s initials

Tuition will not be prorated for illnesses, vacation, or holidays. In the event of illness more than thirty (30) days, exceptions will
be made at the discretion of the Co-Directors.
Parent’s initials


If more than two payments are missed, the student will not be allowed to attend class until account balance is paid in full.
A $10 fee is charged for each returned check. Our bank utilizes a service in collecting unpaid funds that may incur additional
charges. The account will be placed on a cash-only status after 2 returned checks.
Parent’s initials _______
Chesterfield Christian Academy has the right to cancel classes if enrollment does not meet the minimum of six students. In the
event that this is the only class in which a student was enrolled, parents have the option of a refund of the registration fee or to
enroll the student in a different class.
Parent’s initials _______
PAYMENT PLAN (Check One)

____
Option 1: Full tuition in one payment due by August 7, 2016. Invoices with total amount will be sent electronically.
______ Option 2: Pay by semester. Invoices with total amount will be sent electronically and half of the total is due in two payments
due on August 7, 2016 and January 7, 2017. . Parents’ social security numbers are mandatory when choosing Option 2.
Option 3: Ten monthly installments (Annual tuition divided by 10) due the 7th of each month. Invoices with total amount will
be sent electronically. The first payment is due August 7, 2016 and the tenth payment is due May 7, 2017. Parents’ social security
numbers are mandatory when choosing Option 3. There is a late fee of $15 for payments received after the 7 th.
Payments can be made in person at either CCA location OR mailed to:
CCA
PO Box 1711
Midlothian, VA 23113
I have read, understand, and agree to all terms in the Tuition Agreement.
Signature of parent or guardian
Date
Signature of parent or guardian
Date
____________________________________
Father’s Social Security Number
____________________________________
Mother’s Social Security Number
(mandatory for Option 2 & 3)
Last Name _______________________________________
Chesterfield Christian Academy
COURSE REQUEST FORM
STUDENT INFORMATION AND COURSE REQUESTS (please list study halls needed)
1ST 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:
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:
3rd 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.
*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 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
Registration fees are $75.00 per student with a $210 maximum per family. There are discounted prices for registering before June 1, 2016.
All registration fees are non-refundable.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Office Use Only: Amount
Date received
Check # _______
Cash
Administration initials