Liberty Christian Academy Admission Form
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A registration payment must accompany this form in order to submit registration.
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Email *
School Year of Enrollment *
Child's first, middle, and last name. *
Grade entering *
Gender *
Address *
Mobile Number *
Date of Birth *
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I am re-registering as a previous LCA student. *
If a new student to LCA, last school attended?  *
Primary Language Spoken *
Marital Status of Parents *
Father's Name *
Father's Place of Employment *
Father's Mobile Number *
Father's Address  *
Father's Social Security Number *
Mother's Name *
Mother's Place of Employment *
Mother's Mobile Number *
Mother's Address (if not the same as Father's Address) *
Mother's Social Security Number *
Name of church if attending *
Public School district residence (Please select one) *
To receive family discounts, please list names and grades of any other children in your family who are applying for registration at LCA. *
Please list any other names other than parents that need to be contacted in case of an emergency. Please include Their relationship and phone number. *
Who were you referred by? *
Does your child have any medical needs? *
Please detail all Medical needs for your child *
Does your child have an IEP? Students will be accepted if their needs are able to be met by LCA. If yes, please provide a copy of the IEP. *
Has your child been suspended or expelled from any school? LCA is unable to accept students who have been expelled from any school. *
If yes, please explain below. *
Registration fees are not refundable for any reason unless an opening is UNAVAILABLE.  Rejected applications shall receive a 50% refund of registration. *
Please select one of the Tuition rates listed below *
Required
Enrollment Contract

1st child annual tuition rate: $6,350.00 - ($200.00 discount if paid in full by September 1, 2024)

2nd child discounted annual tuition rate: $5,080.00 - (no additional discount if paid in full)

The second and additional child tuition rates are only for children in the same immediate family and living in the same residence. Tuition is an annual charge to be paid in advance, however may be paid in monthly payments, either through ACH automatic bank withdrawal, or a financing fee of $20 per month per child will be charged for cash, check or credit card payments. If you choose monthly payments, payments are due on the 1st of each month. At the close of the 10th of each month all past due accounts will receive a 3% late charge. ACH payments will be processed on the 4th of each month. A $30 service charge will be assessed for any and all returned checks, $35 for all stopped checks.  

Early Withdrawal Policy: Upon withdrawing, a $250 early withdrawal fee will be charged in addition to any tuition charges due for each student withdrawing for any reason before the end of the 2024-2025 school year, even if the child never attends.  If the 12 month payment plan is chosen, June and July tuition charges will be credited and tuition will be charged in compliance with the 11 month plan. Withdrawals in July will also incur the July tuition charge. Beginning August 1, a credit of ½ month tuition will be applied for withdrawals between the 1st and 15th of the month.

 Liberty Christian Academy does not discriminate as to race, color, creed, national and ethnic origin to all the rights, privileges and activities generally accorded or made available to students at the school.  It does not discriminate on the basis of race, national and ethnic origin in administration policies, scholarship, tuition assistance, athletic and other school administered programs.

I understand and agree that continued enrollment of my child(ren) in this school is dependent on my parental support of the school, its staff and its policies.



Electronic Signature of Father/Guardian *
Electronic Signature of Mother/Guardian *
I recognize the above electronic signatures are as binding as a written signature and therefore agree to the terms listed above within the contract. *
Required
Please provide a copy of the Child's birth certificate, and current records of vaccinations by July 10, 2024. Records must be received before student attends school.
ACH Authorization Form

If your child is a returning student, and you have an ACH setup with your account, please sign below. I authorize Liberty Christian Academy to use my current financial information that is on file for the 2024 - 2025 school year.

I hereby authorize Liberty Christian Academy (LCA) to initiate debit/credit entries to my account in the entity named below (Bank/Credit Union). This authorization is to remain in full force and effect until agreement is revoked. Any revocation shall not be effective until LCA has received written notification from me of my desire to terminate this agreement in such time and in such manner as to give LCA a reasonable opportunity to act on it. LCA reserves the right to revoke this agreement at any time. Funds are to be available by the fourth day of the month. Any/all Non-Sufficient Funds charged back to the school will result in a $40.00 service fee. Any charge backs may result in revocation of this ACH agreement. Debits are made on the fourth of each month or shortly thereafter in an amount of the full account balance, beginning in the month following the month in which this authorization is received.



Parent/Guadian Name
Social Security Number
Bank/Credit Union Account Holder Name
Bank/Credit Union Name
Bank/Credit Union Address
Account Type
Clear selection
Routing Number
Account Number
Institution Account Holder's E-Signature
Date of Signature
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A copy of your responses will be emailed to the address you provided.
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