RPCA Student Information Form
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HOME & FAMILY INFORMATION
Student's Full Legal Name  *
Student nickname (preferred  name)
Student's Birthday *
MM
/
DD
/
YYYY
Student's age (in years) *
Gender *
Social Security Number *
Ethnicity *
Parent/Guardian Contact Number *
Parent/Guardian Primary Email *
Home Address (line 1) *
Ex: 123 Main Street
City of Residence *
Ex: Ooltewah
State of Residence & Zip Code *
Ex: Tennessee 37363
County of Residence *
Ex: Hamilton
Zoned Public School *
Most Recent School Attended *
If homeschooled, include the umbrella here
Address of Most Recent School *
If homeschooled, put N/A
Phone # of Most Recent School *
If homeschooled, put N/A
Who does the student primarily reside with? *
Who primarily brings the student to school? *
Who primarily picks up the student from school? *
Guardian 1 Full Name *
Guardian 1 Relationship to Student *
Guardian 1 Primary Phone *
Guardian 1 Primary Email *
Guardian 1 Marital Status *
Guardian 2 Full Name *
Guardian 2 Relationship to Student *
Guardian 2 Primary Phone *
Guardian 2 Primary Email *
Guardian 2 Marital Status *
SIBLINGS ATTENDING THIS SCHOOL:
List any siblings' names and grades also attending RPCA
Sibling 1 Name & grade:
Sibling 2 Name & grade:
Sibling 3+ Names & grades:
TECHNOLOGY INFORMATION
The school asks students in grades 3 - 8 to bring a device that can be used at school to access the internet and complete assignments that require technology. Students in grades 5 through 8 should bring a Chromebook, Laptop, Smartbook, or other device that has a keyboard for typing. Grades 3 and 4 can still bring a tablet-style device, though a Chromebook is still recommended. Typing skills should begin as young as 3rd grade to ensure proper technological education occurs by middle school. (For Kindergarten through 2nd grade students, devices are optional but highly recommended and should be Tablet style)
Does the student have a personal device to bring to school? *
If yes, what type?
Do you have home internet access? *
EMERGENCY Contact Information
Please list at least ONE emergency contact besides the guardians to reach in case of emergencies. 
Emergency Contact 1 Name *
Emergency Contact 1 Relationship to student *
Emergency Contact 1 Phone Number *
Emergency Contact 1 Email *
Emergency Contact 2
Emergency Contact 2 Relationship to student
Emergency Contact 2 Phone Number
Emergency Contact 2 Email
ADDITIONAL EMERGENCY CONTACTS:
Include here any other emergency contact names, numbers and emails below:
AUTHORIZED PICKUP PERSONS
Without an RPCA car tag, all persons will be required to show photo ID to the front office for student pick-up. If a person is not listed as a guardian, emergency contact, or an authorized pickup person, RPCA will NOT allow them to pick up the student.
Authorized Pickup person 1
Authorized Pickup person 2
Authorized Pickup person 3+
Include here any other authorized pickup persons names below:
STUDENT ACADEMIC INFORMATION
Grade level registered for *
Highest grade level completed *
Medical / Allergy Issues *
List of medications *
All medications must be kept at the front desk in a secure location and administered by the front desk secretary.
All health records, including immunization forms, must be sent to the school upon request *
Does the student have an active IEP or 504 already in place? If yes, documentation must be provided to the school. *
What academic concerns do you have for your student, if any? *
What social concerns do you have for your student, if any? *
Are there any other concerns, comments, or important information you want to inform the school of that is not already listed? *
List the Extracurricular Activities your student participates in (or is interested in) *
Records and Forms for Enrollment
Please confirm you can provide upon request any other documentation for the school (i.e. birth certificate, most recent report card, prior test results, social security number, etc.)
 *
Please confirm the student has no discipline record, or a copy of all discipline reports can be provided to the school
 *
List of other possible forms to be requested at the convenience of the school:

1. Academic and Church Reference Forms if needed

2. Discipline record or a copy of all discipline reports.

3. A transcript of the student’s permanent record to date, including grades for courses in progress

4. The student’s complete testing profile

5. Attendance records

6. All health records, including immunization form, eye, ear & dental form, birth certificate, etc.

7. For Exceptional Education:

       o All psychological reports 

       o Individual Educational Plan (IEP)

       o Eligibility Report

       o 504 documentation

8. Agreement to uphold the student handbook

9. All forms found referenced within the student handbook

STATEMENT OF FAITH
We believe the Bible to be the inspired Word of God and our standard for faith and practice. We believe in God as revealed in the Bible. He, as our eternal heavenly Father, is the author of truth, love, and faith. We believe in the deity of the Lord Jesus Christ, in His virgin birth, in His sinless life, in His vicarious and atoning death, in His bodily resurrection, and in His second coming. We believe in the Holy Spirit who empowers for service and reveals Jesus in us. We believe that man was created in the image of God, fell through disobedience, and is saved through faith in Jesus Christ.
Do you agree with the statement of Faith as stated above?
 *
Family's Home Church
 *
I certify that all the information above is true and accurate to my current knowledge. 
 *
Type full name below for electric signature
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