Welcome to our online registration for new students!

Directions for registering your child for Headwaters Christian Academy.

1.  Read all the documentenation in the links below.  You will be required to confirm that you have read and will comply with the information in the Parent-Child Handbook using the link below.

• Headwaters Parent-Child Handbook

• Headwaters 2022-2023 Calendar DRAFT –  to be finalized by 3/1/2023 (we mostly follow ISS calendar)

2.  Fill out all required information in the registration form below. Your registration will not submit if all required fields are not completed.  You will see a confirmation screen if your registration submitted successfully.   Please include any and all information in detail. These forms are the first step towards ensuring that your child’s records are accurate,

3.  After submitting this form there are a couple of steps that still have to take place.

• Yearly Registration Fee will need to be paid.  Registration is not complete until you have submitted your $125 registration fee (per child).

  • — Registration fees will be refunded if your application is not approved.  In the event you are placed on a wait list, you will be notified and we will retain your registration fee to hold your place on the list.

  • — Registration fees can be dropped by or mailed to our office at 2659 S Chipley Ford Rd, Statesville, NC 28625.  Please make checks are payable to South River Baptist Church with Headwaters Registration Fee in the memo field.

    If you would prefer to pay via checking account, debit or credit card you can use this link > https://onrealm.org/headwaters/give/regfee

• We will review your Registration and check for availability in your child’s grade level.  If full, you may be put on a waiting list. Enrollments are based on a first-come, first-serve basis.

4.  Starting 2/1 we will begin to confirm with you via email of your child’s registration status that will include next steps.  If your child cannot be registered, the office will contact you in order to notify you of our decision and the reasons why we have denied registration.

5.  Your Yearly Resource Fee will need to be paid in full before your enrollment is considered complete.  A link for payment will be sent in the registration confirmation email.

If you have any questions, please contact Kim williams at 704-876-1520 ext 112 or kim@southriverbaptist.com. We look forward to enriching your child’s education this year!

• STUDENT INFORMATION:

• Child's Name*
  First Middle Last Goes By
• Birth Date*
  Month

  Day

  Year
• Gender:*
  Gender at Birth
  • Male
  • Female
• Applying for Headwaters Academy for Grade:*
  Note: Pre-K must be at least 4 by 8/31/23 and K must be at least 5 by 8/31/23.
  Pre-K (3 days)Pre-K (5 days)K1st2nd3rd4th5th6th7th8th9th10th
• Applying for After School Care Program?*
  After School Care hours are from the end of Headwaters school day, 2:30pm, until 6p Mon-Fri. It will be an additional $200 per month for each child enrolled regardless of how many days they attend.
  • Yes
  • No
• Home Address:*
  Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

• EMERGENCY CONTACT INFORMATION:

• 1st Emergency Contact Name*
  First Last
• 1st Emergency Contact Relationship*
• 1st Emergency Contact Phone*
• 2nd Emergeny Contact Name*
  First Last
• 2nd Emergency Contact Relationship*
• 2nd Emergency Contact Phone*

• FAMILY INFORMATION:

• Father or Guardian Name*
  First Last
• Address*
  Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code
• Mobile Phone*
• Email*
  Enter Email Confirm Email
• Occupation:*
• Employer:*
• Name of church where you are a member:*
• Attending Regularly?*
  • Yes
  • No
• Church City/State*
  City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
• Mother or Guardian Name*
  First Last
• Address:*
  Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code
• Mobile Phone*
• Email*
  Enter Email Confirm Email
• Occupation:*
• Employer:*
• Name of church where you are a member:*
• Attending Regularly?*
  • Yes
  • No
• Church Address*
  City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
• Parent's Marital Status:*
  MarriedSeparatedWidowedDivorcedSingleOther
• Child resides with:*
  Both ParentsMotherFatherGuardian
• Number of children living in the home:*
• Are there any custodial issues?*

• PREVIOUS SCHOOL INFORMATION

• School Last Attended (list homeschool if applicable):*
  If child was previously in homeschool please list the name of your homeschool. For children that are going into Pre-K or K please list name and address of daycare instead of school, if applicable. If no previous school please put NA.
• School Address:
  School, daycare or homeschool address
  City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code
• Has the child ever been retained?*
  • Yes
  • No
• If yes, which grade?
  K1st2nd3rd4th5th6th7th8th9th10th11th12th
• Has the child ever been suspended?*
  • Yes
  • No
• If yes, please state reason:
• Has the child ever had any difficulty with the Civil Authorities?*
  • Yes
  • No
• If yes, please give the details and reason for the difficulties:
• Are there any factors in the child's life (i.e. absence of father or mother, physical limitations, or disabilities) that may affect his/her progress or activity in school?*
  • Yes
  • No
• If yes, please indicate:
• Has the child experienced any learning difficulties or been diagnosed with any learning disabilities or disorders such as Dyslexia, ADD, ADHD, Autism, etc... ?*
  • Yes
  • No
• If yes, please explain and list any medications they are taking:

• Agreement with Fees and Policies

  Links to documents and handbooks where applicable, are included at the top of this form.
• We agree to pay the Registration Fee of $125 per child.*
  Fee due with submission of this form (see details at the top of this form for payment options.) Registration is not complete until fee is submitted. ----------------- This registration fee includes one Headwaters T-shirt and one end of year test. Testing is only for children grade 1st and up.
  • Yes
• We agree to pay a one time, per child Resource Fee upon registration approval.*
  Pre-K $250 per child, K-5th $400 per child, 6th-9th $500 per child. Resource Fee is due upon registration approval to confirm enrollment in Headwaters Academy.
  • Yes
• We agree to commit to paying Headwaters fees in the following manner:*
  See tuition and fee schedule in the Parent-Child Handbook.
  • I prefer to pay a lump sum payment
  • I prefer to pay monthly installments
• We understand that images of our child may be captured and used through video, photo and digital camera, to be used solely for the purposes of promotional material and publications, and we waive any rights of compensation or ownership thereto.*
  • Yes
• Upon enrollment approval and we will submit the required additional Medical and Liability form as well as additonal forms as required.*
  Form must be submitted prior to attending 1st day of school
  • Yes
• Upon enrollment approval we will submit the required immunization documentation required by the State of North Carolina.*
  Immunization records are required before attending the first day of of school.
  • Yes
• We have received and read the Parent-Child Handbook V3.0. We understand and will abide by the terms and policies as presented in the document.*
  • Yes
• We confirm that all the information submitted in this form is accurate and truthful*
  • Yes
• How did you hear about Headwaters?*
  • Referral (list name below)
  • Social Media
  • Brochure
  • Church Event
  • Radio
• If someone recommended Headwaters to you, please list their name below.
• Date*
  MM slash DD slash YYYY
• Signature of Father or Gaurdian*
• Signature of Mother or Guardian*