St. Mary's Academy New Student Application

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

New Student Application

New Student Application

Student Information
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*
Date Format: MM slash DD slash YYYY
Place of Birth*
Religion*
Parish*
City*
Baptized*
- Yes
- No
(If yes, please supply Baptismal Record)
Baptism Date
Date Format: MM slash DD slash YYYY
Parish
City
First Communion*
- Yes
- No
First Communion Date
Date Format: MM slash DD slash YYYY
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.
- American Indian
- Black (not of Hispanic origin
- Asian
- Hispanic
- White (not of Hispanic origin)
Family Information
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*
- Mother and Father
- Mother
- Father
- Mother and Stepfather
- Father and Stepmother
Name of Student's Legal Guardian (if applicable)
First Last
Name of Student's Stepparent (if applicable)
First Last
Student Medical and Emergency Information
Emergency Contacts (other than child's parents or guardians)
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
Medical
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?
Agreements
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.
General Information
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?
Please list family members who have attended
Name
First Maiden Name (if applicable) Last
Years Attended
Address
Street Address Address Line 2 City State ZIP Code
Referred by
Phone
This field is for validation purposes and should be left unchanged.

There are no upcoming events at this time.

« July 2020 »