Collierville First pentecostal church

Kingdom Christian Academy

Student Information

Student's First Name

Student's Last Name

Student's Birthdate

Social Security Number (optional)

Grade Level for 2025-26

Gender

Prerequisite for admission to KCA

*Birth Certificate(photo copy)

Immunization Record

Prior School Record(if applicable)

Social Security Card(photo copy)

Please email all documentation to Regina.blanton@colliervillefpc.com

Mother's First Name

Mother's Last Name

Mother's Phone Number

Mother's Email

Father's First Name

Father's Last Name

Father's Phone Number

Father's Email

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Emergency contacts (other than parents) List names & phone numbers

Authorized people to pickup child from the school. Please list names and phone numbers.

Has child repeated a grade?

Yes

No

If yes, what grade?

Last school attended

Reason for selecting KCA

In case of emergency, i give permission to the school authorities, or its representatives to obtain medical treatment of my child in my absence.

I agree

I do not agree

As the Parent I give the staff of KCA permission to paddle my child if deemed necessary. Communication with parents will always be the first line of action in such situations.

Yes

No

Enrolling my child for homeschool days at KCA means these are formal school days. I'll assist as needed, knowing that the 4 in-person days keep tuition lower. Not following homeschool guidelines may raise tuition and require 5 days in person.

I agree

Child's physician

Physician's Phone Number

Allergies

List any physical difficulties:

Liability Waiver : I hereby release and agree to hold Kingdom Christian Academy(KCA)/Collierville First Pentecostal Church (CFPC) harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, Claims, demands, damages, cost, expenses and compensation for damage or loss to myself, my heirs and/or property that may be caused by any act, or failure to act on the school/church, or that may otherwise arise in anyway in connection with any services KCA/CFPC. I understand that this release discharges KCA/CFPC from any liability or claims that I, my heirs, or any personal representatives may have against the school/church with respect to any bodily injury, illness, death, death, medical treatment, or property damage that may arise from, or in connection to, any services received from KCA/CFPC. This liability waiver and release extends to the school/church together with all owners, partners, and employees.

I Agree

Signature

Please email all documentation to Regina.blanton@colliervillefpc.com

Student Information

We Baptize in Jesus Name

Service Times

Contact Info

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