» Residential Program Application

Residential Program Application

Step 1 of 3

Student's Information

Name *

First

Last

Student's Current Grade *

Grade applying for: *

Gender *

Male
Female

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Parent #1 Information

Name *

First

Last

Home Phone

Mobile Phone *

Business Phone

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Workplace/Business name

Workplace/Business Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent #2 Information

Name

First

Last

Home Phone

Mobile Phone

Business Phone

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Workplace/Business name

Workplace/Business Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical Information

Does the applicant have any chronic illnesses, physical disabilities, or psychological conditions for which the applicant has been treated, has received medication, or would affect full participation in the scholastic or athletic programs of Williamsburg Christian Academy? *

Address of Treating Physician: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Address of Additional Treating Physician: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Student Essay

Please respond to one of the following topics: 1. Write about someone you consider to be successful and why you chose that individual. 2. Pretend that you have an unlimited amount of financial resources. In detail, describe how you would spend the money. 3. Adolescents positively impact our world each day. How do you intend to contribute to Williamsburg Christian Academy? *