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You may apply using the application below. If you have a question at any time, you may call (928-251-2859) or email ([email protected]) with your questions.

Step 1 of 10 - Student Information

Student(s) Information

How Many Students Are You Registering?(Required)

Student's Full Name(Required)

First Middle Last

Grade Entering(Required)

Date of Birth(Required)

Gender(Required)

Race(Required)

Citizenship(Required)

Primary Language Spoken at Home(Required)

Birthplace(Required)

City State / Province / Region Country

Current & Previous Schools

Schools Previously Attended(Required)

Additional Student Information

Has the student ever repeated a grade or been dismissed from school?(Required)

Has the student ever been diagnosed with any learning, emotional, psychological disabilities or identified for special education programs (e.g. resource room, IEP, Attention deficit, etc)?(Required)

Has the student ever been tested or received special help for a reading or learning disability?(Required)

Briefly state your child’s strengths and weaknesses.(Required)

Medical Authorization & Information

Family Doctor

Doctor's Phone Number

Doctor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Hospital

Family Dentist

Dentist's Phone Number

Student #1 Medical Conditions

Please state the student's name & any medical conditions we should be aware of.

Student #1 Medications

List any prescription medications.

Instruction for Administration of Medication

Allergies

Do You Authorize WMCA To Administer Recommended Dosage Of Acetaminophen (Tylenol) If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Antacid (Tums) If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Antibiotic Ointment (Neosporin) If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Anti-Itch Ointment (Calamine) If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Chapstick/Carmex If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Cough Drops If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Eye Wash/Artificial Tears If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Ibuprofen (Advil, Motrin) If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Oral Antihistamine (Benadryl) If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Antiseptic Wound Wash If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Dextromethorphan (Robitussin) short acting cough medicine If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Diphenhydramine (Benadryl) ointment If Needed?(Required)

Do You Authorize WMCA To Administer Recommended Dosage Of Children’s Loratadine (Claritin) for allergies If Needed?(Required)

Insurance & Consent

Name of Health Insurance Company

Policy Number

Group Number

Consent(Required)

I agree to the medical release form.

I hereby authorize White Mountain Christian Academy to give and/or obtain emergency medical assistance for my student in the event that I cannot be reached. I also assume full financial responsibility for any such medical service rendered.

Second Student