Student Information

Family Information

Student Medical and Emergency Information

Emergency Contacts (other than child's parents or guardians)

Medical

Agreements

General Information

Please list family members who have attended

Student Information

Family Information

Student Medical and Emergency Information

Emergency Contacts (other than child's parents or guardians)

Medical

Agreements

General Information

Please list family members who have attended

April Break – No School

April Break – No School

Memorial Day – No School

New Student Application

Enrollment for Grade*

For PreK 3 enrollment, please specify ½ day or full day. For PreK 4 enrollment, please specify 3-day or 5-day

Name*

First Middle Last

Gender*

Male
Female

Address

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

Phone*

Date of Birth*

Place of Birth*

Religion*

Parish*

City*

Baptized*

Yes
No

(If yes, please supply Baptismal Record)

Baptism Date

Parish

City

First Communion*

Yes
No

First Communion Date

Parish

City

School Previously Attended (including pre-school)*

Address*

City State / Province / Region

Grade(s) Attended*

Please enter a number from 0 to 12.

School Previously Attended (including pre-school)

Address

City State

Grade(s) Attended

Please enter a number from 0 to 12.

Will the above named child require busing?*

Yes
No

Race

Responses to the following item are not required. However, your assistance with this information is greatly appreciated.

Father*

First Name Last Name

Father Employment*

Occupation Place of Employment City State

Father Home Telephone*

Father Work Telephone*

Father Religion*

Religion Parish City State

Father Email*

Mother*

First Name Last Name

Mother Employment*

Occupation Place of Employment City State

Mother Religion*

Religion Parish City State

Mother Email*

Sibling 1 Name

First Last

Sibling 1 Age

Please enter a number from 1 to 100.

Sibling 1 Gender

Male
Female

Sibling 1 School

Sibling 2 Name

First Last

Sibling 2 Age

Please enter a number from 1 to 100.

Sibling 2 Gender

Male
Female

Sibling 2 School

Sibling 3 Name

First Last

Sibling 3 Age

Please enter a number from 1 to 100.

Sibling 3 Gender

Male
Female

Sibling 3 School

Student Lives With*

Name of Student's Legal Guardian (if applicable)

First Last

Name of Student's Stepparent (if applicable)

First Last

Emergency Contact 1 Name*

First Last

Emergency Contact 1 Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact 1 Relationship*

Emergency Contact 1 Phone*

Emergency Contact 2 Name

First Last

Emergency Contact 2 Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact 2 Relationship

Emergency Contact 2 Phone

Emergency Contact 3 Name

First Last

Emergency Contact 3 Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact 3 Relationship

Emergency Contact 3 Phone

Physician's Name*

First Last

Physician's Address*

Street Address Address Line 2 City State ZIP Code

Physician's Phone*

Dentist's Name*

First Last

Dentist's Address*

Street Address Address Line 2 City State ZIP Code

Dentist's Phone*

Name of Policy Holder (Medical Insurance)

First Last

If you do not have medical insurance, the diocese requires that you purchase school accident insurance

Medical Insurance Policy Company

Medical Insurance Group Number

Does your child have food allergies (for example, peanuts)?*

Yes
No

If yes, please list

Does your child have allergic reactions (for example, bee stings)?*

Yes
No

If yes, please list

Does your child take medications on a daily basis?*

Yes
No

If yes, please list

Does your child require medication to be administered during school hours?*

Yes
No

Does your child require special education services?*

Yes
No

Is there anything else you would like us to know about your child?

Individual Responsible for Payment of Tuition and Fees:

Name

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Consent*

In registering our child, I (we) agree to meet the financial and service commitments outlined. Further, I (we) agree to abide by the guidelines established in the school handbook and recognize that failure to do so could result in dismissal.

How did you hear about our school?

What most influenced your decision to enroll your child?

What do you hope your child will gain from this experience?

Name

First Maiden Name (if applicable) Last

Years Attended

Address

Street Address Address Line 2 City State ZIP Code

Referred by

Comments

This field is for validation purposes and should be left unchanged.

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