2023-2024 Student Application-Preschool

1. Please be sure you complete all required field in the application. Incomplete applications will not be processed.
2. A copy of the student's birth certificate and health form must be submitted for enrollment to be complete. This can be delivered or mailed to 31 Crossroads Lane Fishersville 22939.
3. The $50 registration fee must be paid in full in order for the application to be processed. You may pay online, with cash, or check. This can be delivered or mailed to 31 Crossroads Lane Fishersville 22939.
4. A Family Interview will be conducted follow the completion of the application. Interviews will be scheduled per family not per child(ren).
Upon acceptance to ACA, families will complete additional enrollment forms.

Program Selection

Extended Care Options

I do not plan to use Extended Care I plan to utilize drop in Extended Care as needed Reserved AM Extended Care on enrolled days starting at 6:30 am Reserved AM Extended Care on enrolled days starting at 7:00 am Reserved AM Extended Care on enrolled days starting at 7:30 am Reserved PM Extended Care on enrolled days until 4:00 pm Reserved PM Extended Care on enrolled days until 5:00 pm Reserved PM Extended Care on enrolled days until 6:00 pm

Student Information

Name (First, Middle) Last

Gender

Male Female

Date of Birth

Address

Primary Phone

Primary Email

This address will receive a confirmation email

Primary Language

Has your child been enrolled in, or recommended for, any of the following to support his/her development/learning

OT PT Speech Vision Cognitive Behavior Therapy Academic None of the above

Please explain any of the items selected above

Has your child been referred to school administration for discipline

Yes No

Please explain if you selected

Has your child ever been suspended or asked to unenroll from a school

Yes No

Please explain if you selected

Family Information

Father's Name (First, Middle, Last)

Address

Home Phone

Cell Phone

Work Phone

This address will receive a confirmation email

Occupation

Employer

Mother's Name (First, Middle, Last)

Address

Home Phone

Cell Phone

Work Phone

This address will receive a confirmation email

Occupation

Employer

Marital Status of Parents

Married Separated Single Divorced Widowed

Sibling #1 Name

Sibling #1 Age

Sibling #1 Gender Male Female N/A

Sibling #2 Name

Sibling #2 Age

Sibling #2 Gender Male Female N/A

Sibling #3 Name

Sibling #3 Age

Sibling #3 Gender Male Female N/A

Sibling #4 Name

Sibling #4 Age

Sibling #4 Gender Male Female N/A

Church and Community

Are you currently attending church

Yes No

Name of Church

Pastor's Name

List any community organizations or activities your family is currently (within the past 3 years) have been involved with

Family Questions

Why have you decided to enroll your child(ren) in ACA

What do you see as your part in your child's education

How did you learn of our school and what prompted your application

What are the strengths of your child

What are areas for growth for your child

Do you plan to apply for financial assistance

Yes No

In what areas would you like to support ACA through volunteering

Morning Drop off and Start of Day Afternoon Dismissal and End of Day Cafeteria Classroom helper Office helper Special Events only Field trips Extended Care Activities

Confirmation Statements

By checking the boxes below, you are acknowledging the the statements are true and of representation of your family.

Please review each statement and select to acknowledge

I have read, understand, and acknowledge the ACA Statement of Faith All information provided in the application is complete and accurate I understand that the enrollment fee, birth certificate, and health form should be submitted in order for enrollment to be complete. I acknowledge that my enrollment fee is nonrefundable.

Payment

Review and Select each payment option/price before completing the form. Card payments included the transaction fee.

PRE-K Enrollment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2023-2024 Student Application-Preschool

Description

Please Fix the Following