• Parent/Guardian #1 Parent/Guardian #2
• Name* Name*
• Relationship* (Mother, Father, Step-parent, Guardian, Grandparent, Deceased) Relationship* (Mother, Father, Step-parent, Guardian, Grandparent, Deceased)
• Marital Status* (Married, Single, Widowed, Divorced, Remarried, Separated) Marital Status* (Married, Single, Widowed, Divorced, Remarried, Separated)
• Street Address* Street Address*
• City, State Zip* City, State Zip*
• Home Phone* Home Phone*
• Work Phone Work Phone
• Email Address* Email Address
• Religion Religion
• Employer Employer
• Occupation Occupation

• Direct Correspondence to:
• Street Address
• City, State Zip
• County of Residence
• PhonePublish in School Directory
• Email* Publish in School Directory
• Language(s) Spoken In Home
• Names and birth dates of ALL children in family (list pre-school children first)
• Boys
• Girls
• Custody(if applicable)SingleJointName(s)

• If you and the physician of your choice, as indicated on back, cannot be reached in an emergency and, if in the judgement of the school authorities, immediate medical and/or hospital attention is indicated, do you authorize the school authorities to send your child (properly accompanied) to an available hospital or physician?

• YesNoSignature*

• As a parent and/or guardian, I authorize the treatment of a minor child/children by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger child’s life, cause physical disability or undue
  discomfort if delayed. This consent is granted only after reasonable effort has been made to reach me.

• YesNoSignature*

Student Information

• Name* Proposed Grade Placement
• Date-of-Birth* Birth City/State/County
• Gender*MaleFemale Oldest Child?YesNo
• First Language Child Learned to Speak Language Child Speaks Most Often
• Current Parish*
• For Pre-School or Pre-Kindergarten students:
• Preschool (3-4 years old)
  (Please choose one)5 days (M-F)3 days (M,W,F)
  (students must be 3 by 8/1 and fully toilet trained)Pre-Kindergarten PK (4-5 year old)
  
  5 days (M-F)
  
  (students must be 4 by 8/1 and fully toilet trained)
• After School, child goes to:
• Place* Phone*
• Contact*

Religious Records

Sacrament	Date	Church	City, State Zip
Baptism
First Eucharist
First Reconciliation
Confirmation

Health/Emergency Information

• First Contact
• Name* Relation*
• Phone*
• Second Contact
• Name* Relation*
• Phone*
• Doctor
• Name* Address
• City* State
• Phone*Preferred Hospital*
• Hospital Address* Hospital City/State
• Health/Physical Limitations
• Medication(s)
• Instructions/Allergies
• Immunization Expiration Date
• Transferred Information
• School Entered
• Address Withdrew
• Reason Code1 - Completed Program2 - Moved3 - Illness4 - Parent Choice5 - Other
• Current Teacher
• Phone
• Email
• Transferred Information
• Signature*

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