VLA Application

Victory Life Academy

Submission of a student application does not assure enrollment but rather provides much of the information upon which a decision will be based.

A non-refundable Registration Fee must accompany this Student Application.

(New students must also include their birth certificate, immunization record and most recent grade card.)

If the student is placed on a class waiting list, the registration fee will hold his/her place until the second day of school. If no space becomes available by that time the student’s name may be withdrawn from the waiting list and a full refund will be paid. (Voluntary withdrawal from the waiting list prior to the second day of school will result in the loss of the registration fee.)

Victory Life Academy reserves the right to make final decisions concerning student placement.

STUDENT PERSONAL INFORMATION GRADE ENTERING: _______________

Student: ____________________________________________________ ___________________________

Last First Middle Goes by:

Mailing Address: ____________________________________________ ___________________________

Street/PO Box City/State Zip Home Phone

Social Security # _____ / _____ / _______ Date of Birth: _____ / _____ / _______ Age: _____ Sex: _____

General Health: _________________________ Blood Type: _____________

List any allergies, handicaps, or other pertinent health information: ______________________________________

Race / Ethnicity: Requested but not required. Information is used for grant and funding proposals for VLA.

[ ] African American

[ ] Asian

[ ] Caucasian

[ ] Hispanic

[ ] Native American

[ ] Other: ______________________________________

PARENT / GUARDIAN INFORMATION

A. Father / Guardian: ______________________________________________ ________________________

Last First Middle Home Phone:

Mailing Address: _________________________________________________ ________________________

Street/PO Box City/State Zip Cell Phone:

Social Security # _______ / _______ / __________

Employer: _______________________________________________________ ________________________

Work Phone:

[ ] Lives with student [ ] Emergency Contact [ ] Allowed to pick up student

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A. Mother/Guardian: ______________________________________________ ________________________

Last First Middle Home Phone:

Mailing Address: _________________________________________________ ________________________

Street/PO Box City/State Zip Cell Phone:

Social Security # _______ / _______ / __________

Employer: _______________________________________________________ ________________________

Work Phone:

[ ] Lives with student [ ] Emergency Contact [ ] Allowed to pick up student

EMERGENCY CONTACTS

Contact Name: ____________________________________________________ Relation: __________________

Home Ph: (_____) _______________ Bus. Ph: (_____) _______________ Cell Ph: (_____) _______________

Contact Name: ____________________________________________________ Relation: __________________

Home Ph: (_____) _______________ Bus. Ph: (_____) _______________ Cell Ph: (_____) _______________

Contact Name: ____________________________________________________ Relation: __________________

Home Ph: (_____) _______________ Bus. Ph: (_____) _______________ Cell Ph: (_____) _______________

MEDICAL CONTACTS

Physician: ____________________________________________________ Phone: (_____) _______________

Dentist: ____________________________________________________ Phone: (_____) _______________

Hospital: ____________________________________________________ Phone: (_____) _______________

Insurance: ____________________________________________________ Phone: (_____) _______________

Policy Number: ____________________________

PEOPLE (OTHER THAN PARENTS) AUTHORIZED TO PICK-UP STUDENT FROM SCHOOL

Name: _________________________________________________ Daytime Phone: (_____) _______________

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SCHOOL ATTENDANCE HISTORY: List all schools previously attended, beginning with the most recent.

REASON FOR

YEAR SCHOOL CITY & STATE DISTRICT & ADDRESS WITHDRAWAL

Has the student ever been denied admission to a school? [ ] Yes [ ] No

If yes, why? _______________________________________________________________________________

Has the student ever been suspended or expelled from school? [ ] Yes [ ] No When? __________________

If yes, why? _______________________________________________________________________________

Name of school: ____________________________________________________________________________

SPIRITUAL INFORMATION REGARDING THE STUDENT:

Home Church: __________________________________________________ Phone: (_____) _______________

Name Address/City/State/Zip

Church Currently

Attending: __________________________________________________ Phone: (_____) _______________

Name Address/City/State/Zip

Denomination: ____________________________________

Senior Pastor: _______________________________ Youth Pastor: ___________________________

Has the student accepted Jesus Christ as his/her personal Lord and Savior? [ ] Yes [ ] No Year ________

Is the student living a Christian life to the best of his/her ability? [ ] Yes [ ] No

Comments: ___________________________________________________________________________________

_____________________________________________________________________________________________

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PARENT / GUARDIAN QUESTIONNAIRE [Attach additional sheets as necessary.]

What do you perceive to be your child’s strengths? ___________________________________________________

___________________________________________________________________________________________

What do you perceive to be your child’s greatest needs?

Spiritual: ___________________________________________________________________________________

Behavioral: _________________________________________________________________________________

Academic: _________________________________________________________________________________

Social: _____________________________________________________________________________________

Has your child used drugs, alcoholic beverages, or tobacco? [ ] Yes [ ] No

If yes, please explain in detail: ___________________________________________________________________

____________________________________________________________________________________________

How would you rate your child’s attitude toward: God . . . . . . . . . . . . . . . . . . . . . . [ ] Positive [ ] Negative

Parents . . . . . . . . . . . . . . . . . . . . [ ] Positive [ ] Negative

Authority Figures . . . . . . . . . . . . [ ] Positive [ ] Negative

Will your child be an asset or a liability to VLA? _____________ Why? _________________________________

____________________________________________________________________________________________

PARENT AGREEMENT: Please read and sign the attached forms.

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AFFIRMATION:

I hereby affirm that all of the information contained in the student application is true and accurate to the best of my knowledge. I understand that false information can result in enrollment denial and dismissal from Victory Life Academy.

___________________________________________________ ______________________________

Student Signature Date

___________________________________________________ ______________________________

Father / Guardian Signature Date

___________________________________________________ ______________________________

Mother / Guardian Signature Date

STATEMENT OF NONDISCRIMINATION

It is the policy and practice of Victory Life Academy, in the admission of students or the hiring of employees, not to discriminate on the basis of the applicant’s race, color, sex, national or ethnic origin, or reasonably accommodating disability.

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