Enrollment Application

Victory Christian Academy · Virtual — Wisconsin families, K–12. A few minutes to begin; someone will follow up personally.

Family

Family last name *

Primary email *

Primary phone *

Street address *

City *

State *

ZIP *

State of residence *

VCA Virtual enrolls Wisconsin families.

Parent / Guardian

First name *

Last name *

Relationship *

Phone *

Email *

Second parent / guardian (optional)

First name

Last name

Relationship

Students

Student

First name *

Last name *

Grade (fall) *

Date of birth *

Sex *

Academic pathway

Previous school *

This student has an IEP or 504 plan

How you plan to enroll

Funding source *

Number in your household *

Everyone living in your home, including your students. Wisconsin uses household size with income to determine Choice eligibility.

Telemedicine (optional — Vitae Health)

Interested in Vitae Health telemedicine for your student?

No / not right now Yes, I’m interested

Current primary care provider (optional)

Preferred pharmacy (optional)

Adults authorized to consent to care

I acknowledge Vitae Health’s Notice of Privacy Practices.

I understand telemedicine is provided by Vitae Health, a separate provider from the school.

I consent to telehealth care for my student.

These three boxes are required only if you selected “Yes.”

Acknowledgments (all required)

The information I’ve provided is true and complete. *

I agree to review the family handbook and school policies. *

I agree to receive enrollment text messages from VCA Virtual. Msg & data rates may apply; reply STOP to opt out. *

I give permission for my student’s photo to be used in school materials. *

Anything else we should know?

Soli Deo gloria. · Victory Christian Academy · Virtual