St. Catherine of Siena - St. Lucy School
Student Application for 2021 - 2022
Email address *
SECTION 1: STUDENT INFORMATION
_______________________________________________________________________________________________________
New or Returning Student *
Student First, Middle, and Last Name: *
Birth Date: *
MM
/
DD
/
YYYY
Gender: *
Race (check all that apply): *
Required
Is student Hispanic / Latino *
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? *
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? *
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? *
Parent's martial status: *
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: *
MM
/
DD
/
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