A MINISTRY OF UPPER ROOM CHURCH OF GOD IN CHRIST The

The Upper Room Christian Academy exists to partner with families and churches
to prepare students for biblical, academic and social excellence.
A MINISTRY OF UPPER ROOM CHURCH OF GOD IN CHRIST
3330 Idlewood Village Drive Raleigh, North Carolina 27610 (919) 829-6250
Dear Prospective Parent,
Thank you for your interest in Upper Room Christian Academy. We are a distinctively Christian school
committed to educational excellence for each student in our program from 18 months old through 5th grade.
As a Classical Christian Education school, we are dedicated to preparing preschoolers for success in grade
school and school students for effectively approaching middle school and beyond with confidence and excellence. We are a fully accredited academic institution through (SACS) Southern Association of Colleges and
Schools and (ACSI) Association of Christian Schools International.
Upper Room Christian Academy has had the privilege of providing Christian education to the Raleigh
community for over 10 years and we have positively impacted thousands of students over that time. Our focus
and commitment is to provide the finest quality of an academic experience possible; that instills each student
with a Biblical worldview, Christian values and Character development to prepare them for success in the
Kingdom of God and in the community as productive citizens. In addition to its comprehensive curriculum,
URCA is known for its safe family environment, its caring qualified faculty and staff committed to excellence,
providing a strong spiritual foundation, upholding high standards in academics and discipline and for its
superior standards based athletic program. It is our desire to be an extension of the family by assisting parents
in preparing students for Biblical, academic and social excellence.
Thank you again for your consideration of this great school. We understand how vital and important the
choice you make will be in deciding where your student will attend school. It is our desire to provide the information and support needed to assist you in this process.
We invite you to take a tour of our facility to see our faculty and students actively engaged in the learning
experience, URCA style.
May the Lord bless you in your endeavor to provide Christian education for your children.
It is a sacrifice that’s worth it!
Yours in Christian Service,
Elder John Amanchukwu
Executive Director
How to Apply
Admission Policy & Procedure
The Upper Room Christian Academy (URCA) admits students of any race, color, national or ethnic origin to all the
rights, privileges, programs and activities generally accorded or made available to students of the school. URCA
does not discriminate on the basis of race, color, national and ethnic origin, the administration of its educational
policies, enrollment policies, scholarships, athletic programs and other school-administered programs. URCA
reserves the privilege of setting and maintaining our own standards of student conduct, dress, tuition, fees for
services and scholarships. URCA reserves the right to refuse admission or to dismiss anyone who violates the
school’s standards set forth in the Parent/Student Handbook or as defined by the school board and or
administration. URCA also reserves the right to change any policy as deemed necessary with or without notice.
URCA is committed to providing the best possible education for every child accepted in our program. The
admissions process consists of collecting and receiving an application, previous school records, teacher
recommendations, interviews, assessing the needs of the student, and willingness of the family to partner with the
school’s mission and vision. Please use the admissions process checklist to ensure that all necessary information is
collected.
Entrance Requirements
Students seeking admission to URCA may be required to take an entrance test to determine proper grade
placement. Administration may accept recent standardized test scores from another school or psychologist if
available. It will generally be necessary for a student to score on or above the grade level being requested. If
entrance tests are required, they will be scheduled by our school Principal.
Students applying for entrance to our Kindergarten program should be turning 5 years old on or before
October 31st.
We have completed the application. What’s next?
After the application is processed, the parents/guardians will be contacted by the Admissions Office to schedule an
interview with the prospective family and student(s) to finalize the process. The interview provides an opportunity
to fellowship with one another, to hear your families’ goals and aspirations, and to evaluate how we can best serve
your student(s). Academy Administrators will review the application, test scores, transcript/grade reports and
interview information. Prospective student placement or diagnostic testing will be administered. Applicants will
be notified of enrollment status by mail or by phone. Once accepted, applicant must pay $90.00 to complete the
registration fee. After the student(s) has been accepted, the Admissions Office will issue the Welcome Packet and
explain the billing/payment process with the family.
A child will be officially enrolled and given a class assignment:
After he/she is accepted
After the annual registration fee of $150.00 has been paid
After the annual resource fee of $300 has paid
After the first month’s tuition has been paid
We look forward to meeting your family, and will be in prayer with you as you embark upon
your choice for Christian education.
Admissions Process Checklist
Listed below are the required steps for admission into the Upper Room Christian Academy. A student will not be
officially enrolled until all necessary documents have been received. Interested families are to submit a completed
application with the $60.00 application fee. The application fee is non-refundable and will be applied to the registration fee of $150.00 if the student is accepted into the school.
 Call the school to schedule a tour of URCA or you may do so at www.urcap.org
 Complete and sign an application for each child applying - both parents are required to sign
 Application Processing Fee - attach a check made payable to URCA for the non-refundable amount of $60.00.
 Birth Certificate – Must be an official copy

 Student Immunization Records – Due by Sept. 1st for all new students
Students turning 12 years old must provide documentation showing a DTAP immunization within the past
four years.
 Report Cards – previous 2 years
 Records Request Form – Complete, sign and return with the application
 Pastor’s Reference – must be signed and dated by a parent or guardian, then completed by your church
pastor. The form must be mailed or faxed back to URCA from the pastor
 Teacher’s Reference – a teacher of the applicant must complete the form and mail or fax back to URCA
 Kindergarten Health Assessment - completed by a doctor within 30 days after the start of school
 Student Handbook – Parents are encouraged to review the Student Handbook
to become familiar with our
established policies and procedures. An electronic copy of the handbook can be found at the www.urcap.org.
 Statement of Cooperation – Complete, sign and return with the application
 SMART Tuition Enrollment Form – Complete, sign and
return with the application
 After your application is processed, you will be contacted by the admissions office to schedule an interview
with you and the prospective student (s) to finalize the process.
 Initial
Fees - A child will be officially enrolled and given a class assignment after the Annual Registration Fee
of $150, Annual Resource Fee of $300 and the first month’s tuition has been paid. All fees are non-refundable.
Please be sure to follow these guidelines to avoid delays in the application process.
Please return to URCA Admissions Office at:
3330 Idlewood Village Drive Raleigh, North Carolina 27610 or fax to (919) 829-6193
ELEMENTARY TUITION and FINANCIAL INFORMATION 2013/14
Tuition Cost: The cost of tuition is represented by the Full Amount Due.
Payment Options:
For grades K-5 we have devised 2 payment options:
10 month payment plan- with the first tuition due August 1st
12 month payment plan-with the first tuition payment due June 1st
Late Fees: All monthly payments are due to Smart Tuition by the scheduled due date. A $35.00 late fee will be assessed to your account for all payments that are past due. All past due tuition and late fees must be paid if your student
is to remain in the school.
Dishonored Payments: A fee of $25 will be applied to your account for any failed auto-debit and failed check payments.
Your bank may impose additional fee.
Tuition Refund: There will be no refund for absences from school. Exceptions may only be made in the case of
hospitalization of your child with a serious illness. A doctor’s note will be required.
Suspension for Non-Payment: Elementary students will not be allowed to attend class when their accounts are over
30 days delinquent. Students are subject to dismissal if their account is not brought current or an acceptable payment
arrangement is not made within 60 days. Students suspended more than twice within a school year for non-payment
may be dismissed from URCA.
Application Processing Fee: $60.00 per student for new students only (non-refundable). Due with application.
Annual Registration Fee: $150.00 per student due upon acceptance or re-enrollment (non-refundable)
Annual Resource Fee: $300.00 per student (non-refundable) Due in full before 1st day of class.
Grade Level
Full Amount Due
(receive 3% discount if paid in full
10 Month Pymt Plan
August-May
12 Month Pymt Plan
June-May
K-5
$5100
$4947 w/discount
$510/monthly
$425/monthly
Extended Care Rates
Available Upon Request
Available Upon Request
Available Upon Request
ELEMENTARY
Multiple child discount:
**10% for 2nd student, 15% for 3rd student and each additional student
Upper Room Church discount:
**10% 1st student, 15%for each additional student
Church discount:
** 10% per student-must have at least 10 students to qualify
**(not applicable with any other discount)
Additional Financial Information:
Return Check Fee: A fee of $35 will be charged for all returned checks. This fee will be automatically billed to your
account when a return check is received.
SMART Tuition: If you choose to pay monthly, all tuition payments are made to SMART Tuition. All families must
complete a SMART application upon enrollment. Information and sign-up for SMART is located on the URCA website, www.urcap.org.
Tuition Assistance: Tuition Assistance awards are determined according to a family’s demonstrated need based on
information collected by SMART Tuition. SMART is a third-party agency that makes financial needs assessments for
schools. SMART uses information supplied by the applicant to assess financial need. Applications can be fill out
online from the SMART Tuition link or an application can be picked up in the Administrative Office. The decision to
provide assistance is determined solely by URCA using the assessment from SMART and other factors as deemed necessary. Each award is made in the form of a tuition discount, is for one year only, is based on availability of tuition
assistance funds and is awarded to returning families first. Applications submitted after that date will be reviewed and
awards will be based on the amount of assistance remaining. New students must be accepted by URCA before tuition
assistance can be requested.
Early Withdrawal: The school budget and teacher contracts are set based on students being enrolled for the entire
school year. An early withdrawal of a student creates an unexpected hardship on the school and an opening that may
not be filled. Therefore, students who are withdrawn before April 1st will be accessed a fee of $500 per child. In
addition, any paid fees are non-refundable and all books and supplies are forfeited.
InfoDirect: InfoDirect™ is a feature designed to help connect the school to the home by means of a secure Internet
connection. With a user ID and password, parents will be able to check lunch menus, upcoming events, get directions
to a sporting event and download homework assignments.
Annual Fund: Each family is requested to give a yearly tax deductible gift to the Annual Fund. These contributions
will provide additional financial resources to be used to expand and improve the programs and services of URCA. It is
very important that every family participates and we ask that you pray about what amount to give.
No Billing Statements: URCA does not send statements or invoices. All billing is done through Smart Tuition.
Records: Records will not be forwarded to another school until all financial obligations to the school are met. Report
cards must be held by the school at the end of the year if there is an unpaid balance. Report cards will not be issued if
you have an overdue balance.
Early Arrival/After School Care: If your students attend before or aftercare on a monthly basis, the monthly fees will
be added to your SMART Tuition account. Payments are due in advance at the beginning of the month of service.
Families will be charged $1.00 for every minute a child remains in aftercare pass 6:00pm.
Meal Program: URCA offers a student choice meal program. Students have the option of ordering lunch from one of
URCA’s vendors or bringing a nutritious bag lunch from home. Vendor meals must be ordered a month in advance
through www.orderlunches.com which offers a secure, fast and easy to use, online ordering solution that provides the
ability to view your school’s meal menu, order, pay, and manage your meals orders online.
ENROLLMENT APPLICATION
Date of Application: ____________________________________________ Number of Applicants: ___________________________
How did you learn about Upper Room Christian Academy?
_____________________________________________________________________________________________________________________________
Applicant: ____ New Student ____Returning_____ Aftercare: _____Yes _____No Early Arrival: ____Yes ____ No
Payment Plan: ____ Full Payment _____10 Month _____12 Month (10 and 12 month payments received by SMART Tuition)
Applicant Information
Applicant 1
Name: _______________________________________________________________________________________________________________________
First
Grade Applying For:
Middle
K 1 2 3
Male:___________ Female:__________
4 5
Preferred Name: _________________________________________________________________
Birth:(Month/Day/Year)_____/_____/________
Citizenship: US or Other__________
Last
Place of Birth: ___________________________________________________________
Last School Attended: ___________________________________________________________
Applicant 2
Name: ________________________________________________________________________________________________________________________
First
Grade Applying For:
Middle
K 1 2 3
Male:___________ Female:__________
Last
4 5
Preferred Name: ________________________________________________________________
Parent/Guardian Information
Father’s Name: ___________________________________________ Mother’s Name: ____________________________________________
Street Address_____________________________________________ Street Address_______________________________________________
State:______ City:___________________ Zip Code: ____________ State:______ City:____________________ Zip Code: ___________
County: _____________
County: _____________
Home Phone: ________________Cell Phone: ________________ Home Phone: __________________ Cell Phone: ________________
Work Phone: ______________________________________________ Work Phone:_________________________________________________
Father’s Email Address____________________________________ Mother’s Email Address_____________________________________
Father’s Employer: ________________________________________ Mother’s Employer: _________________________________________
Employer’s Street Address: ______________________________ Employer’s Street Address: ________________________________
City: ____________________________ State: ___________________ City: ____________________________ State: _____________________
Zip Code: ________________ County: ________________________ Zip Code: ________________ County: __________________________
Maternal Grandparents
Paternal Grandparents
Name(s): __________________________________________________
Address: __________________________________________________
City: _____________________State: ___________ Zip: __________
Phone: ____________________________________________________
Name(s): ____________________________________________________
Address: ____________________________________________________
City: _____________________State: ___________ Zip: ____________
Phone: ______________________________________________________
*If a parent has primary custody, URCA requires copies of the custodial legal documents to be provided to the
Admissions Office with application.
The applicant(s) live with:
___Both Parents
___Father
___Mother
___Grandparent(s)
___Other
Is Parent(s) deceased – Specify: _________________________________________________________________________________________
Parents marital status: ____________________________Who has custody: __________________________________________________
Who Receives Mail: ___________________________________ Who pays tuition: ______________________________________________
Church Membership: ____________________________________________________________________________________________________
Pastor’s Name: __________________________________________ How long Active Member: __________________________________
Street Address: __________________________________________________________________________________________________________
City: ______________________________________________ State: ______________ Zip Code: _____________________________________
Father: Christian? _______Yes __________ No If yes, briefly state your salvation experience.
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Mother: Christian? _______Yes _________ No If yes, briefly state your salvation experience.
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Emergency Medical Information
Emergency Contact: _______________________________________Best Phone Contact: _______________________________________
Scholastic Information
Applicant 1 Previous Level of Academic Performance: ( ) Excellent ( ) Above Average ( ) Average ( ) Below Average
Has student ever repeated a grade: ( ) No ( ) Yes – What grade: ___________________________________________________________
Has student ever been expelled, suspended, or refused admission to another school? ( )No ( )Yes
If yes, please identify and explain.___________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Has student ever had any disciplinary difficulties? ( )No
( )Yes If yes, please identify and give details
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Address of Previous School: ________________________________________________________________________________________________________
Name of Contact Person____________________________________________________ Phone: ________________________________________________
Are there any reasons that the student cannot participate fully during normal school activities, including athletics or
extracurricular? ( ) No ( ) Yes – Please explain:_______________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Are there any special factors, conditions, learning differences, including any special medications or allergies affecting
the student of which the school needs to be informed? ( ) No ( ) Yes – Please explain:____________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Applicant 2 Previous Level of Academic Performance: ( ) Excellent ( ) Above Average ( ) Average ( ) Below Average
Has student ever repeated a grade: ( ) No ( ) Yes – What grade: ____________________________________________________________
Has student ever been expelled, suspended, or refused admission to another school? ( )No ( )Yes
If yes, please identify and explain.__________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Has student ever had any disciplinary difficulties? ( )No
( )Yes If yes, please identify and give details
_________________________________________________________________________________________________________________________________________
Applicant 3 Previous Level of Academic Performance: ( ) Excellent ( ) Above Average ( ) Average ( ) Below Average
Has student ever repeated a grade: ( ) No ( ) Yes – What grade: __________________________________________________________
Has student ever been expelled, suspended, or refused admission to another school? ( )No ( )Yes
If yes, please identify and explain.
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Has student ever had any disciplinary difficulties? ( )No
( )Yes If yes, please identify and give details
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Address of Previous School: ____________________________________________________________________________________________________
Name of Contact Person____________________________________________________ Phone: ___________________________________________
Are there any reasons that the student cannot participate fully during normal school activities, including athletics or
extracurricular? ( ) No ( ) Yes – Please explain:_____________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
The Upper Room Christian Academy admits students of any race, color, national or ethnic origin to all the rights, privileges, programs and
activities generally accorded or made available to students of the school. URCA does not discriminate on the basis of race, color, national and
ethnic origin the administration of its educational policies, enrollment policies, scholarships, athletic programs and other school-administered
programs. We reserve the privilege of setting and maintaining our own standards of student conduct, dress, tuition, fees for services and
scholarships. The school reserves the right to refuse admission or to dismiss anyone who violates the school’s standards set forth in the Parent/
Student handbook or as defined by the school board and or administration. The school also reserves the right to change policy as deemed
necessary.
Are there any special factors, conditions, learning differences, including any special medications or allergies
affecting the student of which the school needs to be informed? ( ) No ( ) Yes – Please explain: ______________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
STATEMENT OF COOPERATION
FINANCES: We understand it is necessary that parents pay tuition for the amount stated on the Tuition and Financial Information
statement. If tuition payments and fees are not received by the due date of each month, a $35.00 late charge will be added to the account.
Tuition that becomes 30 days past due will result in the student being withheld from attending school until such amounts due to URCA are
made current. If the account is not brought current with 60 days of the due date the student may be dismissed from the school. A fee of $35.00
will be charged for each returned check. All tuition payments are made via electronic funds transfer, by check or credit card to SMART TUITION. The full month's tuition is due for any month in which the student attends one school day. All fees are due in full and are nonrefundable. Refunds are for tuition only and will be made on accounts that are paid beyond the current month. All fees are non-refundable.
EARLY WITHDRAWAL FEE: A withdrawal fee of $500.00 must be paid if student is withdrawn prior to the end of the school year. Records
will not be released until the account is paid in full to include the Early Withdrawal Fee.
SCHOOL ACTIVITIES: We give permission for our child(ren) to take part in any and all school activities, class field trips, including sports
and school sponsored trips away from the school premises and absolve the school from liability to us or our child because of any injury to
us or our child at school or during any school activity. In case of emergency or serious illness, we request the school contact us first. If we
are not available, please contact the designated emergency contact(s). If the emergency contact(s) cannot be reached, the school has our
permission to make whatever arrangements deemed necessary for our child(ren)'s treatment. If the emergency is life-threatening and we
cannot be reached, the physician has permission to act accordingly absolving the school of any liability. This statement of cooperation will
serve as a blanket permission slip from my child’s date of enrollment unless otherwise notified by me the parent or legal guardian. We
understand that in order to participate as a volunteer we must abide by the guidelines set forth in the volunteer policy and have all
necessary forms completed.
RIGHTS OF USE AND REPRODUCTION: We authorize URCA or anyone authorized by URCA, to use and reproduce all audio and video tapes
and photographs which URCA takes of our child(ren) or any family member produced for school literature, advertisements, and
promotional purposes without further compensation. All copies, masters, negatives, pictures and proofs shall constitute URCA property,
solely and completely.
DISCIPLINE: We believe discipline is a necessary aspect of our child(ren)'s education. We give permission for our child(ren)'s teacher and/or
administration to make and enforce classroom regulations in a manner consistent with Christian principles and discipline as set forth in
Scriptures and outlined in our handbook. We understand that we have the responsibility to actively support the authority, philosophy,
objectives, policies, procedures, and discipline of the school as established by the School Board. We understand that we may be called and
required to come discipline our child. I agree to do this and understand that failure to fulfill this requirement may result in losing the privilege for my child to be served by Upper Room Christian Academy. I have been personally informed of these procedures.
PARENTAL COMMITMENT: We agree that we will in no case complain to other parents, but will register only necessary complaints with
the teacher or administration following the Matthew 18 principle. We pledge our full cooperation to keep doctrinal controversy out of the
school. We agree to support the school with our prayers and positive attitude. We understand that if at any time the school determines, in
its sole discretion, that our actions do not support the ministry, or reflect a lack of cooperation and commitment to the home and school
working together, the school has the right to request the withdrawal of our child(ren). Admission to Upper Room Christian Academy is a
privilege and not a right. It is a privilege granted with the understanding that students will desire to live as Bible-believing, consecrated
Christians. Conduct exemplary of developing young Christians is expected. Drinking alcoholic beverages, using marijuana or other illegal
drugs, smoking, profanity, disrespect for authority or property, improper sexual behavior and abuse of others by us, our child or any person
visiting the school on our behalf are prohibited on our campus and discouraged in the home and private time away from school.
Inappropriate clothing and playing loud music when visiting the school are not allowed. This applies to school and non-school related social
activities where unacceptable behavior would have an adverse effect on the testimony of the school. As a URCA family, we will commit to
the principle of the sanctity of marriage between a man and a woman.
FAITH STATEMENT: The general nature and object of Upper Room Christian Academy shall be to conduct an institution of learning for the
general education of youth in the essentials of culture and its arts and sciences, giving special emphasis to the Christian faith and the ethics
revealed in the Holy Scriptures that young people may be prepared spiritually, academically and socially for every good work. We
believe in accordance with the Upper Room Church that the Bible is the inspired and only infallible written Word of God; that there is One
God eternally existent in Three Persons: God the Father, God the Son, and God the Holy Spirit; we believe in the Blessed Hope, which is the
rapture of the church of God, which is in Christ, at His return; that the only means of being cleansed from sin, is through
repentance, faith
in the precious Blood of Jesus Christ and accepting the gospel according to Romans 10:9-10; that regeneration by the Holy Ghost is absolutely essential for personal salvation; that the redemptive work of Christ on the Cross-provides healing for the human body in answer to
believing prayer; that the baptism in the Holy Ghost, according to Acts 2:4 is given to believers who ask for it; and we believe in the sanctifying power of the Holy Spirit, by whose indwelling the Christian is enabled to live a holy and separated life in this present world.
We have read and are in agreement with the (1) Application, (2) Student Handbook (on line at www.urcap.org), (3) URCA Statement of
Cooperation and the (4) Tuition and Financial Information Statement and hereby agree to abide by their stated policies. I further agree
to hold the school, church and its agent harmless for any liability to my child or any parent or guardian thereof because of any claims on
behalf of my child against the church, school or any agent thereof because of any injury to my child. Should legal action, for any reason, be
taken against URCOGIC or URCA or any employee or agent thereof on my child’s behalf, and the church, school or its agents not be found at
fault, I agree to pay any attorney fees, court fees, damages or other costs that Upper Room COGIC or Upper Room Christian Academy or its
agent should incur to defend itself against such action. This Statement of Cooperation will be in effect for as long as my child(ren) listed (or
others to be enrolled attend this church school.
Student’s Name ___________________________________________________________________________________________________________ _Date ___________________________
Parent or Guardian Signature _____________________________________________________________________________________________Date ___________________________
Parent or Guardian Signature _____________________________________________________________________________________________Date ___________________________
Administrator’s Signature _________________________________________________________________________________________________Date ___________________________
UPPER ROOM CHRISTIAN ACADEMY
Confidential Teacher Reference
TO BE COMPLETED BY THE PARENTS:
Parents, please complete the signature lines below and submit the reference form to a teacher who has taught your child in a
core subject (math, reading, language arts, history, or science). For families with multiple applicants, please copy this form
to provide one for each applicants’ teacher. Submit the sealed envelope(s) with your completed application or the teacher
may mail it or fax it to the admissions office.
I give permission for the following information to be released to Upper Room Christian Academy. I understand that it will be
treated confidentially and will not be released to me or anyone else other than the administration of Upper Room Christian
Academy.
Name of Student: ___________________________________________________ Grade applying for: ________________________________________________
Signature of Parents: ________________________________________________________ Date: _______________________________________________________
TO BE COMPLETED BY THE PERSON MAKING THE RECOMMENDATION:
The student named above is a candidate for admission to URCA. We would appreciate your completing this form within
five to seven business days after receiving it from the family. You may return it to the family in a sealed envelope, fax to
(919) 829-6193, or mail to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610. Please sign on the
reverse side. Thank you.
How long have you known the student? ___________ How well? ____________________________________________________________________
In what subject(s)/grade(s) did you teach him/her? ______________________________________________________________________________
Is this student average, above average, or below average in performance? ______________________________________________________
Is the family supportive of the school and the teacher? ____________________________________________________________________________
What are this child’s greatest strengths? ____________________________________________________________________________________________
Does he/she have special academic needs? _________________________________________________________________________________________
Do you have any concerns regarding the success of this student? _________________________________________________________________
In what ways has this student displayed evidence of good character?_________________________________________________________________
1.
2.
3.
4.
5.
6.
7.
PLEASE RATE AS FOLLOWS:
E= Exceptional
KINDERGARTEN CANDIDATE
____ Letter identification
____Orally identifies beginning sounds
____Orally identifies words that begin the same
____Orally identifies words that end the same
____Orally recognizes rhyme
____Orally segments words into phonemes (sounds)
____Orally divides words into syllables
____Orally substitutes one phoneme for another
A=Acceptable
NS= Needs Support
FIRST thru FIFTH GRADE CANDIDATE
____Reads for a variety of purposes, including for
information and for leisure
____Reads and determines meaning of a wide range of
text, including poems, stories, speeches, news,
reference materials, etc.
____Understands and explain the effects of addition,
subtraction, multiplication, and division on whole
numbers and fractions
____Looks at pictures and able to tell stories
____Identifies patterns and makes predictions
____Listens to stories without interruption
____Writes first and last name legibly
____Speaks in complete sentences using at least five to six
____Follows directions
words
____Counts to ten
____Sort similar objects by color, size and shape
____Write first name legibly
____Follows directions
____Stays on task
____Works independently
____Demonstrates age appropriate gross motor skills
____Has positive self-image
____Respects adult authority
____ Responds positively to correction
____Uses self-discipline
____Participates willingly
____Stays on task
____Works independently
____Has positive self-image
____Respects adult authority
____ Responds positively to correction
____Accepts changes and disappointments
____Uses self-discipline
____Attendance is consistent
____Communicates with teacher
____Communicates and cooperates as a group member
____Uses reason and logic to resolve conflicts
____Participates willingly
UPPER ROOM CHRISTIAN ACADEMY
Confidential Teacher Reference Continued
I recommend this student: ( )Yes
( ) No
( ) With this reservation
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Referring Teacher
Name: (print) ________________________________________________ Signature _____________________________________________________
School Name______________________________________________________________________________________________ Date_______________
Position: ____________________________________________ E-mail______________________________ Work Phone _____________________
Please return within one week to:
URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193
UPPER ROOM CHRISTIAN ACADEMY
Confidential Pastor’s Reference
To the Pastor:
The student named below is a candidate for admission to URCA. We would appreciate your completing this form and returning it
within one week to: URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or Fax to (919) 829-6193.
Name of applicant _______________________________________________________________ Candidate for grade _____________________________
To be completed by any full-time Pastor on staff who is well acquainted with applicant:
On a scale of 1-10 (10 being the highest), how well do you know the family? _____________________________________
Are you currently their pastor or associate pastor? __________________________________________________________________
How would you evaluate the parents in the following areas:
a. Their church relationship, attendance, and loyalty _________________________________________________________________
b. Their personal relationship to Jesus Christ _________________________________________________________________________
c. Their interest in having their child know and walk with the Lord ________________________________________________
d. Do they command respect and obedience from their family? _____________________________________________________
4. To your knowledge, has this applicant accepted Jesus Christ as Savior? ___________________________________________
5. How do the parents support their children's spiritual development?_______________________________________________
6. What level of involvement does the applicant(s) have in your church? ____________________________________________
7. What are the first words that come to mind to describe this applicant? ___________________________________________
I recommend this student: ____ enthusiastically ____ strongly ____ fairly strongly ____ with reservation
Pastor's Signature ______________________________________________________ Date __________________________________________
Position: ________________________________________________________________ Phone ( )
__________________________
Church: _____________________________________________________________________________________________________________________
Address: ______________________________________________City: ____________________State: _______________ Zip_________________
To the Parents:
I/we hereby authorize the release of requested information to complete the admission process at URCA.
I/we understand this is part of my student’s application file.
Signatures of Parents/Guardians: ________________________________________________________ Date: ______________________
Please return within one week to:
URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193
Please return within one week to:
URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193
UPPER ROOM CHRISTIAN ACADEMY
Student Medical Form
Please contact your child’s doctor for a copy of the immunization record. If there are additional immunizations required, please
schedule an appointment with your pediatrician to have the immunizations completed by September 1.
Student_______________________________________________Birth Date____________________________
Parent/Guardian_________________________Address__________________________City_______Zip______
Medical History :(To be completed by parent/guardian)
Is your child allergic to anything? ____Yes ___No
If yes, what?
_____________________________________________________________________________________________________________
_______________________________________________________________
Is your child under a doctor’s care? ___Yes__No
If yes, why?
_____________________________________________________________________________________________________________
_______________________________________________________________
Has your child ever been hospitalized? ___Yes__No If yes, why?
_____________________________________________________________________________________________________________
_______________________________________________________________
Is your child on any continuous medication? __Yes __No
If yes what?
_____________________________________________________________________________________________________________
_______________________________________________________________
Does your child have any history of disease or recurrent illness? __Yes __No
If yes, what?
_____________________________________________________________________________________________________________
_______________________________________________________________
Immunization Record: The required immunizations are listed below. Please secure a copy of your child’s current immunization
record from your doctor’s office or health professional to submit to the office by September 1.
Type of Vaccine
Number of Required Doses
DTaP (diphtheria, tetanus and acellular pertussis)
Polio
5 doses*
Hib (haemophilus influenza type B)
Measles
Mumps
Rubella
Hepatitis B
Varicella (chickenpox)
4 doses
3-4 doses**
2 doses
2 doses
1 dose
3 doses
1 dose***
*The last dose of DTaP must be given after age 4.
**Children beyond their 5th birthday are not required to have any Hib vaccine.
***Vaccination required unless documentation of disease history.
In addition to this form, all Kindergarten students accepted to URCA must have a completed copy of the North Carolina Kindergarten
Health Assessment Report. (copy included in enrollment packet)
The health assessment must be completed by your doctor and returned within 30 days from the start of school.
This health assessment should be scheduled prior to the start of the school so that it will remain current for the student’s entire
Kindergarten academic.
The student must have the completed assessment to remain enrolled in Kindergarten beyond the 30 day period.
Student’s Physician___________________________ Address______________________________________ Phone_________________
Student’s Dentist _____________________________Address______________________________________ Phone ________________
Insurance Company___________________________ Policy Holder__________________________________ Phone ________________
Policy Number_______________________________ Group Number_________________________________________
Please return within one week to:
URCA Admissions Office, 3330 Idlewood Village Drive, Raleigh, NC 27610 or fax to (919) 829-6193
www.urcap.org