St. Catherine of Siena - St. Lucy School

Student Application for 2021 - 2022

Email address *

SECTION 1: STUDENT INFORMATION

_______________________________________________________________________________________________________

New or Returning Student *

New

Returning

New sibling of current family

Student First, Middle, and Last Name: *

Birth Date: *

YYYY

Gender: *

Female

Male

Other:

Race (check all that apply): *

Black / African American

White

Asian

Native American

Other:

Required

Is student Hispanic / Latino *

Yes

Grade Level as of September 2021 *

Name and Address of Last School Attended: *

Student lives with: (last name, first name, relationship) *

Address of student's primary residence: (street, city, state, zip) *

Main Contact Information

Main contact name:

Main contact phone number: *

Emergency Contact Name *

Emergency Contact phone number: *

Required Medical Forms

Physical: All new students entering Kindergarten and 6th grade
Dental: All students entering Kindergarten and all new preschool students
Eye Exam: All students entering Kindergarten and all new preschool students
*All required medical forms must be submitted before student may begin classes.*

For Office Use: Birth certificate copy on file? *

Yes

SECTION II: PARENT INFORMATION

_______________________________________________________________________________________________________

MOTHER'S Information

Mother's name: (last, first) *

Home phone: *

Cell phone: *

Work phone: *

Email address: *

Place of employment and occupation: *

Is mom a graduate of SCSL School? *

Yes

FATHER'S Information

Father's name: (last, first) *

Home phone: *

Cell phone: *

Work phone: *

Email address: *

Place of employment and occupation: *

Is dad a graduate of SCSL School? *

Yes

Parent's martial status: *

Married

Divorced

Separated

Widowed

Other:

Step-parent name(s) (if applicable): last, first:

GUARDIAN Information (if other than parent-provided documentation)

Guardian's name: (last, first) *

Home phone: *

Cell phone: *

Work phone: *

Email address: *

Place of employment and occupation: *

EMERGENCY CONTACT FORM 2021 - 2022

To be completed by the parent / guardian for each child. This form will be kept in the school office.

_______________________________________________________________________________________________________

Student name: (last, first) *

Date of birth: *

YYYY

Grade level: *

List of medical allergies and/or significant medical history: *

Parent / Guardian Name(s): *

Home phone #(s): *

Cell phone #(s): *

Work phone #(s):

Physician Information: (name, phone number, address): *

Medical Insurance Provider: *

Policy / Insurance #: *

EMERGENCY CONTACTS in case parent / guardian can not be reached.

FIRST person to contact in case of emergency:

Name: (last, first) *

Phone # and type (mobile, home, work): *

Relationship to child: *

SECOND person to contact:

Name: (last, first) *

Phone # and type (mobile, home, work): *

Relationship to child: *

THIRD person to contact:

Name: (last, first) *

Phone # and type (mobile, home, work): *

Relationship to child: *

MEDICAL RELEASE

In the event that the undersigned, or our authorized physician, can not be reached and in the judgement of the school, there is a necessity for immediate examination and/or treatment of my child, I agree to assume the financial responsibility for a diagnosis/treatment and/or for medication deemed necessary.

Signature and Date: *

Submit

Never submit passwords through Google Forms.

This form was created inside of St. Catherine of Siena - St. Lucy School. Report Abuse

Forms