Registration Form – St. Patrick School

Grade

Catholic?

Parish

Referred By

Language Spoken at Home

Ages of other Children in the Family

Student Last Name

Student First Name

Student Middle Name

Gender

Male

Female

SSN

Address

City

State

Zip Code

Phone Number

City of Birth

State of Birth

Date of Birth

Religion

Race

Applicant lives with

Father/Guardian Last Name

Father/Guardian First Name

Father/Guardian Middle Name

Father/Guardian Home Phone Number

Father/Guardian Cell Phone Number

Father/Guardian Address

Father/Guardian City

Father/Guardian State

Father/Guardian Zip Code

Father/Guardian Education (Highest Degree)

Father/Guardian Email

Father/Guardian Religion

Father/Guardian Current Marital Status

Married

Divorced

Single

Widowed

Father/Guardian Date of Birth

Father/Guardian Place of Birth

Father/Guardian Place of Employment

Father/Guardian Place of Employment Address

Father/Guardian Occupation

Father/Guardian Work Phone Number

Mother/Guardian Last Name

Mother/Guardian First Name

Mother/Guardian Middle Name

Mother/Guardian Home Phone Number

Mother/Guardian Cell Phone Number

Mother/Guardian Address

Mother/Guardian City

Mother/Guardian State

Mother/Guardian Zip Code

Mother/Guardian Education (Highest Degree)

Mother/Guardian Email

Mother/Guardian Religion

Mother/Guardian Current Marital Status

Married

Divorced

Single

Widowed

Mother/Guardian Date of Birth

Mother/Guardian Place of Birth

Mother/Guardian Place of Employment

Mother/Guardian Place of Employment Address

Mother/Guardian Occupation

Mother/Guardian Work Phone Number

Applicant Baptism Date

Applicant Baptism Church

Applicant Baptism City

Applicant Baptism State

Applicant Baptism Zip Code

Applicant Baptism Country

Applicant First Eucharist Date

Applicant First Eucharist Church

Applicant First Eucharist City

Applicant First Eucharist State

Applicant First Eucharist Zip Code

Applicant First Eucharist Country

Applicant Confirmation Date

Applicant Confirmation Church

Applicant Confirmation City

Applicant Confirmation State

Applicant Confirmation Zip Code

Applicant Confirmation Country

Applicant’s Previous School Attended Name

Applicant’s Previous School Attended Address

Applicant’s Previous School Attended Years

Applicant’s Previous School Attended Name 2

Applicant’s Previous School Attended Address 2

Applicant’s Previous School Attended Years 2

Applicant’s Previous School Attended Name 3

Applicant’s Previous School Attended Address 3

Applicant’s Previous School Attended Years 3

Applicant’s Previous School Attended Name 4

Applicant’s Previous School Attended Address 4

Applicant’s Previous School Attended Year 4

Has applicant been recommended for any accelerated programs?

If so, in what subject areas?

Has applicant been participated in any accelerated programs?

If so, in what subject areas?

Has applicant been evaluated or tested for any special needs and/or learning disabilities?

If so, in what areas?

Type of disability?

Does the applicant have physical (speech, vision, hearing, etc.) limitations that would affect his/her academic performance?

If so, in what areas?

Does the applicant qualify for Special Education services?

If so, in what areas?

Has the applicant repeated any grades?

If yes, what grade(s)?

Reason?

Does the applicant need accommodations and/or assistance with social behavior?

If yes, in what areas?

Comments

Father/Guardian Statement of Commitment Signature

Submission of this application serves as the parents’/guardians’ commitment and agreement to be governed by the policies and procedures outlined in the Saint Patrick School Handbook during the time your child is enrolled in the school. The handbook can be accessed on-line at the following website: www.stpatschool.com The information provided by me on this application is accurate to the best of my knowledge.

Father/Guardian Statement of Commitment Signature Date

Mother/Guardian Statement of Commitment Signature

Submission of this application serves as the parents’/guardians’ commitment and agreement to be governed by the policies and procedures outlined in the Saint Patrick School Handbook during the time your child is enrolled in the school. The handbook can be accessed on-line at the following website: www.stpatschool.com The information provided by me on this application is accurate to the best of my knowledge.

Mother/Guardian Statement of Commitment Signature Date