Enrollment Form for St. Jerome Atrium, 2017-2018
Please complete this form and send the registration deposit of $100 (checks should be made payable to "St. Jerome Academy" with "Atrium" in memo) to reserve your child's place in the 2017-2018 Atrium. Immunization forms are needed for enrolling in the 1:30-3:00 pm, Thursday Atrium. If you are enrolling a second child, please fill out the form a second time -- one form per child.
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Birthdate *
Atrium Level *
Level I is for children ages 30 months-6 years; Level II is for children ages 6-9. Six-year-olds who are not independent readers should apply for Level I.
Previous Atrium Experience *
Please indicate how much previous Atrium experience your child has had. If your child has had both Level I and Level II experience, please check both boxes as appropriate.
School *
Grade *
Please select your child's grade level.
Sacramental Preparation *
Please indicate which response best describes your child's status with respect to having made First Confession and First Holy Communion.
Parent's Title *
Parent's First Name *
Your answer
Parent's Last Name *
Your answer
Email Address *
Your answer
Primary Phone *
Your answer
Emergency Contact *
Please input the name and phone number of at least one emergency contact other than the parent listed above.
Your answer
Pickup Person
Please input the name and phone number of any person(s) you designate to be able to pickup your child from Atrium.
Your answer
Special Needs
Please provide information about any special learning or medical needs your child may have.
Your answer
Medical Instructions *
Please check all that apply.
Class Day *
Please check at least one box and check each day that your child would be available for Atrium. Atrium will be held 3:30-5:30 p.m. one day per week. Please select each day that it would be possible to attend, not just what would be your preferred day(s). If you have a preferred day, please indicate it in the comments box at the end of the survey.
Note: Due to the requirements of the Archdiocese of Washington for St. Jerome Academy during school day hours, in order to enroll your child in the Thursday 1:30 to 3:00 pm Level I Atrium, it is necessary to complete pages 1-2 of the Archdiocese of Washington Immunization Form here: http://www.stjeromes.org/sites/stjeromes.lifeaftersunday.net/files/Archdiocese%20of%20WashImmunization%202010-11.pdf (Submit this Form with initial deposit.)
Your answer
The Atrium aide receives free tuition for her child.
Your answer
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