Registration

Elementary Application

Consent *

I have read and understand the Announcement of 2025 – 2026 Registration and Tuition, and the Parent/Student Handbook for School year 2025 - 2026 and I agree to comply with the policies and procedures set forth within.

First & Last NameTyping your name serves as an electronic signature

Date

Student Information

Child 1

First Name *

Middle Name

Last Name

Preferred Name

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date of Birth *

Grade Requested *

Parent/Family Information

Mother's Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Address Same as Above

Mother's Phone No. *

Mother's Email Address *

Mother's Employer *

Mother's Work Phone No. *

Father's Name *

Father's Email Address *

Father's Phone No. *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Address Same as Above

Father's Employer *

Father's Work Phone No. *

Other Children in the Family NOT enrolled at Faith Christian Academy

How did you hear about FCA? (check all that apply)Road SignInternetFriend*ChurchFlyerOther

*If FCAE was recommended to you, whom may we thank for the referral?

Home Church

If you do not have a home church, are you looking for a home church? You are always welcome at Berea.YesNoMaybe

Emergency Contact & Pick Up Information

Name

Relationship

Phone

This persona MAY or MAY not pick up my childMayMay Not

Medical Information

Child's Name

Allergies

Medications

Additional Info/Concerns

Primary Care Physician

Physician Number

School History

Child's Name

School Attended

Years Attended

Reason for Leaving

Photo & Media Authorization

I give permission for my child’s (children) photo to be taken and used for such purposes.I do not give permission for my child’s (children) photo to be taken and used for such purposes.At times, our staff may be taking photos/videos to promote the Academy. Pictures may be posted on our church website or on our social media accounts. No names will be associated with these photos on the internet. We appreciate your cooperation.

Print Name

SignatureTyping your name serves as an electronic signature

PARENTAL NOTIFICATION RELEASE AND CONSENT

To be signed by both parents

I do hereby release and hold harmless Berea Baptist Church and Faith Community Academy of any and all responsibility due to accident or injury incurred during any and all outings, field trips or events. (A separate parental consent form will be provided for all OFF-PREMISES activities).

I give permission for my child to receive any and all medical attention necessary in the event of any emergency accident, injury etc. under the direction of Berea Baptist Church or Faith Christian Academy, and/or the person(s) listed above as EMERGENCY CONTACTS, until such time as I may be contacted.

I also assume any financial responsibility for any such medical treatment.

Name

SignatureTyping your name serves as an electronic signature

Name

SignatureTyping your name serves as an electronic signature

NON-DISCRIMINATION POLICY

Faith Community Academy admits students of any race, color, or national or ethical origins to all the rights, privileges, programs, and activities made available to students at the Academy. It does not discriminate on the basis of race, sex, color, or national or ethnic origin in administering the school’s educational policies, admission, and other school- administered programs.

FINANCIAL RESPONSIBILITY

I have reviewed the financial obligations required to enroll including all fees and tuition. I will be able to cover the financial obligation according to this Announcement of 2025-2026 Registration and Tuition. If I have difficulty meeting this financial requirement at any time, I agree to contact the school immediately with an explanation and not wait for the school to contact me. I understand the inability to make payments in a timely manner may necessitate withdrawal of my children until such time as our account(s) may be made current. I also understand that no refund of tuition will be made upon the withdrawal of my child except for the following reasons:
- If parents are transferred from the area for a job. One-month notice to be given.
- If the child becomes ill and the doctor recommends withdrawal. A note from the doctor is required.

Responsible Financial Party

Name

SignatureTyping your name serves as an electronic signature

Date

Phone

Your registration application is not considered complete until registration fees have been paid via check for all children listed on this form. $225/child

Check here if Full Pay 8/20/25 option requested rather than 12-month payment plan

Get In Touch

Pre-K & Kindergarten

Location: 15421 Pouncey Tract Rd, Rockville, VA 23146

Telephone: 804-749-4411

Email: [email protected]

School Hours: M-Th: 8:45am – 1:30pm

1st - 5th Grade

Location: 15421 Pouncey Tract Rd, Rockville, VA 23146

Telephone: 804-736-0577

Email: [email protected]

School Hours: M-F: 8:45am – 3:15pm