Liberty Christian Academy Admission Form
A Christ-centered education from grades K-8
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If the field you are filling out does not apply, please mark in the field "N/A."

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. *
Gender *
I am re-registering as a previous LCA student. *
Grade entering *
If a new student to LCA, last school attended? Please provide the address as well. *
Date of Birth *
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Ethnic Origin *
Primary Language Spoken *
Marital Status of Parents *
Address *
Mobile Number *
Father's Name *
Father's Place of Employment *
Father's Mobile Number *
Father's Address (if parents of child are divorced) *
Father's Social Security Number *
Mother's Name *
Mother's Place of Employment *
Mother's Mobile Number *
Mother's Address (if parents of child are divorced) *
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? If yes, please provide a copy once your child is accepted. *
Has your child been suspended or 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
Tuition includes:
• No Book Fees
• No Lab Fees
• No Locker Fees
• No Academic Fees
All are provided in your Tuition payment.
5th-8th Grade students must provide iPad or Chromebook
Enrollment Contract
The second and additional child tuition rates are only for children in 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. All accounts that have not made their tuition payment by the 18th of the month will be subject to removal from school enrollment. A $20 service charge will be assessed for any and all returned checks, $35 for all stopped checks.

EARLY WITHDRAWAL POLICY: Upon withdrawing, a $500 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 2021-2022 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 to the 10 month plan. Withdrawals in August will also incur the August tuition charge. Beginning September 1, a credit of ½ month tuition will be applied for withdrawals between the 1st and 15th of the month.

No employee, agent or representative of Liberty Christian Academy has the authority to vary or supplement the terms of this agreement or the application process.

Liberty Christian Academy admits students of any 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, and 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.
Untitled Title
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.
ACH Authorization Form
If you are currently on ACH you do not need to complete another form.
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 $20.00 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
MM
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A copy of your responses will be emailed to the address you provided.
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