Welcome to our 2024-2025 online registration for new students!

Directions for registering your child at Headwaters Christian Academy.

1.  Please be sure to read all the documentation in the links below.  You will be required to confirm that you have read and will comply with the information on the Statement of Beliefs page and in the Parent-Child Handbook in the registration form.

• Headwaters Parent-Child Handbook v5.0
• Headwaters Statement of Beliefs
• Headwaters Calendar (draft calendar, will finalize by April 1st)

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 below these steps 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 several of steps that still have to take place.

• A Non-Refunable 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 child’s 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 all checks payable to South River Baptist Church with Headwaters Registration Fee in the memo field.

    If you would prefer to pay online 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. Enrollment is based on a first-come, first-serve basis, after all required fees and required registration steps have been completed.

4.  We will begin to confirm via email in early March of your child’s registration status and 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.

• After verified registration, all new students will be required to complete an assessment test for proper grade assignments at Headwaters

• Next step, a tour and family interview will be required with our Administrator and Headmaster

• You will be notified following completion of these step if your enrollment has been approved

5.  Your Non-Refundable 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 enrollment acceptance 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 upcoming year!

• STUDENT INFORMATION:

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

  Day

  Year
• Gender:*
  Gender at Birth
  • Male
  • Female
• T-Shirt Size*
  Youth XSYouth SYouth MYouth LYouth XLAdult SAdult MAdult LAdult XLAdult 2XLAdult 3XLAdult 4XL
• Applying for Headwaters Academy for Grade:*
  Note: Pre-K must be at least 4 by 8/31/24 and K must be at least 5 by 8/31/24.
  Pre-K (3 days)Pre-K (5 days)K1st2nd3rd4th5th6th7th8th9th10th11th
• 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 $220 per month (will be prorated for months we are here less than 18 days) or each child or $14 per day as needed.
  • 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:

  Parents will be contacted 1st and then Emg Contacts will be next ones we contact for any illness or emergency we have with your child.
• 1st Emergency Contact Name*
  First Last
• 1st Emergency Contact Relationship*
• 1st Emergency Contact Phone*
• 2nd Emergency 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:*
  Please select choice child is with more than 50% of the time.
  Biological ParentsBoth Divorced Parents equallyMotherFatherGuardian(s)
• 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
  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
• 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 Belief Statement, Fees and Policies

  Links to documents referenced below and payment links are included at the top of this form.
• We have read and agree to the Headwaters STATEMENT OF BELIEFS & STATEMENT ON MARRIAGE, GENDER, AND SEXUALITY .*
  These statements are available at the top of this form and at this link > https://headwaters-academy.com/beliefs/
  • Yes
• We agree to pay the non-refundable yearly 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 paid. This registration fee includes administrative costs, one Headwaters T-shirt and one end of year test. Testing is only for children grade 1st and up.
  • Yes
• We agree to pay the non-refundable, yearly, per child Resource Fee outlined in description below.*
  Pre-K $250 per child, K-5th $400 per child, 6th-11th $500 per child. Resource Fee is due upon registration approval to confirm enrollment in Headwaters Academy.
  • Yes
• We agree to commit to paying Headwaters tuition in the following manner:*
  Tuition costs are available in the Parent-Child Handbook and on our website.
  • We/I prefer to pay a lump sum payment by August 1st
  • We/I prefer to pay 10 monthly installments starting August 1st
  • We/I will be applying for the NC Opportunity Scholarship and will depend on the scholarship funds to cover for tuition costs in full.
  • We/I will be applying for the NC Opportunity Scholarship to see if we can offset some of the cost of tuition
• We understand that images of our child may be captured and used through videos and photos, to be used on our website and social media platforms 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.*
  Updated immunization records or exemptions are required before attending the 1st day of of school.
  • Yes
• Upon enrollment approval we will submit the required immunization or exemption documentation required by the State of North Carolina.*
  Immunization records are required before attending the first day of of school.
  • Yes
• We have read and agree to the terms and policies as presented in the Parent-Child Handbook V5.0.*
  • 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*