Elementary Registration Form "New" Student ... - St. Peter's School

(For Office Use Only)___________ Registration (return date)___________ Check Number/Amount of Deposit_ _________ Emergency Medical Authorized_________ Active Parishioner Participation Guidelines (if applicable)___________ Tuition Worksheet2013-2014 NEW Student Registration ApplicationSt. Peter’s Elementary SchoolStudent_____________________________________________________________________Last First MiddleAddress_____________________________________________________________________Street City ZipHome Phone ( ) Birth Date_____________SS#____________________Sex: M F 2013-2014 Grade Level ____ Was student ever dismissed from schoolfor academic or disciplinary reasons? _____ If yes, please explain. __________________________________________________________________________________________________Last School Attended ______________________ Address ____________________________Reason for Changing __________________________________________________________FAMILY INFORMATIONFather's NameMother's NameOccupationOccupationEmployerEmployerWork PhoneWork PhoneCellular PhoneCellular PhoneE-mail_____________________________________ E-mail_________________________________________Religious Affiliation__________________________ Religious AffiliationNatural or adoptive parents are (please check) married/living together , separated , divorced ,divorced/remarried , single , deceased - (father , mother )In the event your child would need to be released from school for any reason, he/she will not go withanyone whose name is not listed below._______________________________ __________________ ____________(If parents can’t be reached) (Relationship) (Telephone No.)_______________________________ __________________ ____________(If parents can’t be reached) (Relationship) (Telephone No.)_______________________________ __________________ ____________(If parents can’t be reached) (Relationship) (Telephone No.)If custody of the child(ren) has been granted by a court decree as a result of divorce, separation,adoption, etc., please attach a copy of that decree, unless you have previously done so.

Names (first and last) and ages of all other children in family _____________________________________Catholic Parish in which family is registered (if applicable)_Public school district in which you reside _____________________________________________________Traditional Kindergarten Preference (circle one) AM or PMKindergarten Enrichment (optional program; if desired, circle one) AM or PMMusic Curriculum Preference for Grades 5-6 (Circle one)General music (includes optional choir)Band (instrument, if applicable)Please give a concise statement of each parent’s personal practice of his/her religion.___________________________________________________________________________________________________________List sacraments your child has received (give date, parish, city and state) and give copies of certificates to theschool office (if applicable).Date Parish CityBaptism_________________________________________________________________________________Holy Eucharist ___________________________________________________________________________Reconciliation ___________________________________________________________________________Are there any physical, psychological, emotional factors or personal concerns that need to be addressed for thebenefit of your child? Please explain.Ethnic Background (response is optional - data used in preparing required federal, state, and diocesan reports)Student’s ethnic background is:_____ American Indian/Native Alaskan_____ Hispanic_____ Asian_____ Native Hawaiian/Pacific Islander_____ Black/African American_____ White/Caucasian_____ Multi-racialBy my signature, I attest that the above information is true, that I will fully comply with the School Policies,and that I will settle tuition accounts promptly.SignatureRelationship to Student______________A class roster may be provided for parents who request one (i.e., birthday invitations, etc.). In addition to yourchild’s name, please sign below if you grant permission for the following information to be released as part ofthis roster: parents’/guardians’ names, address, and phone number.Signature