CHOCTAW PRIVATE EDUCATIONAL FOUNDATION, INC.
2017-18STUDENT REGISTRATION
PLEASE COMPLETE BOTH SIDES OF REGISTRATION FORM.
FAMILY NAME
ADDRESS
TELEPHONE NUMBER(S)HOME CELL EMAIL ADDRESS
FATHER'S FULL NAME AND ADDRESS
FATHER'S EMPLOYER JOB DESCRIPTION
FATHER'S TELEPHONE NUMBER HOME WORK CELL
MOTHER'S FULL NAME AND ADDRESS (IF DIFFERENT)
MOTHER'S EMPLOYER JOB DESCRIPTION
MOTHER'S TELEPHONE NUMBER HOME WORK CELL
CHURCH AFFILIATION: FATHER MOTHER
EDUCATION - FATHER - COLLEGE GRADUATE YES NO DEGREE RECEIVED
HIGH SCHOOL GRADUATE YES NO
MOTHER - COLLEGE GRADUATE YES NO DEGREE RECEIVED
HIGH SCHOOL GRADUATE YES NO
NUMBER OF CHILDREN ATTENDING PATRICIAN ACADEMY
NAMES AND AGES OF YOUNGER CHILDREN NOT YET ENROLLED
NAME AND TELEPHONE # OF DOCTOR TO BE NOTIFIED
ALTERNATE DOCTOR AND TELEPHONE #
IF EMERGENCY TREATMENT IS REQUIRED AND PARENTS CANNOT BE REACHED IMMEDIATELY, MAY THE SCHOOL AUTHORITIES USE THEIR OWN JUDGEMENT IN CALLING THE DOCTORS INDICATED ABOVE. IF THE ABOVE DOCTORS ARE NOT READILY AVAILABLE, MAY WE CALL ANOTHER DOCTOR? YES NO IF NO, PLEASE INDICATE BELOW WHAT SCHOOL AUTHORITIES SHOULD DO?
THE FOLLOWING FORMS MUST BE ON FILE IN THE SCHOOL GUIDANCE OFFICE FOR EACH CHILD ENROLLED BEFORE SCHOOL BEGINS:
_____CURRENT STATE OF ALABAMA IMMUNIZATION FORM _____CERTIFIED BIRTH CERTIFICATE (COPY ACCEPTABLE)
FIELD TRIP PERMISSION SLIP INFORMATION (ALLERGIES, TELEPHONE, ADDRESS, EMERGENCY CONTACT(S) AND INSURANCE INFORMATION) IS
CORRECT: YES NO (IF NO, PLEASE COME BY THE OFFICE TO CORRECT AS SOON AS POSSIBLE.)
NAME AND TELEPHONE NUMBER OF PERSON(S) WHO HAVE PERMISSION TO PICK UP CHILDREN FROM SCHOOL AND CAN BE CONTACTED IN CASE OF EMERGENCY WHEN PARENTS CANNOT BE REACHED
UPON REGISTRATION AT PATRICIAN ACADEMY, THE UNDERSIGNED AGREES TO PAY PATRICIAN ACADEMY ALL APPLICABLE FEES AND TUITION FOR THE ENTIRE SCHOOL YEAR. THE SIGNATURE OF THE PARENT OR GUARDIAN CONSTITUTES ACCEPTANCE OF THE POLICIES OF THE BOARD OF TRUSTEES AND THE ADMINISTRATION, THE PROCEDURES AND REGULATIONS AS SET FORTH IN THE STUDENT HANDBOOK, AND THE FINANCIAL TERMS AND CONDITIONS SET BY THE BOARD OF TRUSTEES. I UNDERSTAND THAT REGISTRATION FIGURES ARE USED BY PATRICIAN ACADEMY TO DETERMINE THE COMING SCHOOL YEAR CLASS ENROLLMENT CAPACITY AND FACULTY NEEDS, AND THAT A COMMITMENT MUST BE MADE IN ADVANCE TO RESERVE A PLACE FOR MY CHILD(REN). THESE DECISIONS MUST BE MADE AT REGISTRATION TO ENSURE ADEQUATE RECRUITING TIME FOR NECESSARY FACULTY. BY SIGNING THESE REGISTRATION FORMS, I UNDERSTAND THAT I BECOME OBLIGATED TO PAY ALL APPLICABLE FEES AND TUITION FOR THE ENTIRE SCHOOL YEAR. EXCEPTIONS ARE ALLOWED WHEN THE FAMILY MOVES OUTSIDE OF THE SURROUNDING AREA FOR EMPLOYMENT REASONS. EXTRAORDINARY CIRCUMSTANCES WILL BE EVALUATED ON AN INDIVIDUAL CASE-BY-CASE BASIS BY THE EXECUTIVE BOARD. IN THE EVENT OF DEFAULT OR NON-PAYMENT, THE UNDERSIGNED AGREES TO PAY PATRICIAN ACADEMY=S COLLECTION COSTS, INCLUDING BUT NOT LIMITED TO ATTORNEY=S FEES AND COURT COSTS.
DATE______PARENT OR GUARDIAN SIGNATURE
NO REGISTRATION IS ACCEPTED UNTIL APPROVED BY THE EXECUTIVE BOARD OF DIRECTORS.
THIS CONTRACT IS BINDING UPON THE ATTENDANCE OF YOUR CHILD(REN) ON THE FIRST DAY OF SCHOOL.
PLEASE FILL OUT THE REVERSE SIDE
STUDENT'S FULL NAME GRADE 2017-18
DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER
SEX RACE STUDENT DRIVER ONLY: DRIVER=S LICENSE NUMBER
THE ABOVE NAMED STUDENT___MAY/___MAY NOT BE GIVEN TYLENOL AND___MAY/___MAY NOT RECEIVE MINOR TREATMENT FOR CUTS AND STINGS AS DEEMED NECESSARY BY THE FACULTY AND OFFICE STAFF OF PATRICIAN ACADEMY. STUDENTS WILL NOT BE GIVEN MINOR MEDICAL ATTENTION WITHOUT PARENTAL PERMISSION. TELEPHONE OR VERBAL PERMISSION WILL NOT BE ACCEPTED.
DOES STUDENT HAVE ANY UNUSUAL HEALTH CONDITIONS: YES NO____
IF YES, EXPLAIN
DOES STUDENT HAVE A DIAGNOSED LEARNING DISABILITY? YES NO
IF YES, EXPLAIN
STUDENT LIVES WITH: BOTH BIOLOGICAL PARENTS ONE BIOLOGICAL PARENT/SINGLE PARENT HOME
ONE BIOLOGICAL PARENT/ONE STEP PARENT WITH GRANDPARENT
OTHER, PLEASE EXPLAIN
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STUDENT'S FULL NAME GRADE 2017-18
DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER
SEX RACE STUDENT DRIVER ONLY: DRIVER=S LICENSE NUMBER
THE ABOVE NAMED STUDENT___MAY/___MAY NOT BE GIVEN TYLENOL AND___MAY/___MAY NOT RECEIVE MINOR TREATMENT FOR CUTS AND STINGS AS DEEMED NECESSARY BY THE FACULTY AND OFFICE STAFF OF PATRICIAN ACADEMY. STUDENTS WILL NOT BE GIVEN MINOR MEDICAL ATTENTION WITHOUT PARENTAL PERMISSION. TELEPHONE OR VERBAL PERMISSION WILL NOT BE ACCEPTED.
DOES STUDENT HAVE ANY UNUSUAL HEALTH CONDITIONS: YES NO____
IF YES, EXPLAIN
DOES STUDENT HAVE A DIAGNOSED LEARNING DISABILITY? YES NO
IF YES, EXPLAIN
STUDENT LIVES WITH: BOTH BIOLOGICAL PARENTS ONE BIOLOGICAL PARENT/SINGLE PARENT HOME
ONE BIOLOGICAL PARENT/ONE STEP PARENT WITH GRANDPARENT
OTHER, PLEASE EXPLAIN
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STUDENT'S FULL NAME GRADE 2017-18
DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER
SEX RACE STUDENT DRIVER ONLY: DRIVER=S LICENSE NUMBER
THE ABOVE NAMED STUDENT___MAY/___MAY NOT BE GIVEN TYLENOL AND___MAY/___MAY NOT RECEIVE MINOR TREATMENT FOR CUTS AND STINGS AS DEEMED NECESSARY BY THE FACULTY AND OFFICE STAFF OF PATRICIAN ACADEMY. STUDENTS WILL NOT BE GIVEN MINOR MEDICAL ATTENTION WITHOUT PARENTAL PERMISSION. TELEPHONE OR VERBAL PERMISSION WILL NOT BE ACCEPTED.
DOES STUDENT HAVE ANY UNUSUAL HEALTH CONDITIONS: YES NO____
IF YES, EXPLAIN
DOES STUDENT HAVE A DIAGNOSED LEARNING DISABILITY? YES NO
IF YES, EXPLAIN
STUDENT LIVES WITH: BOTH BIOLOGICAL PARENTS ONE BIOLOGICAL PARENT/SINGLE PARENT HOME
ONE BIOLOGICAL PARENT/ONE STEP PARENT WITH GRANDPARENT
OTHER, PLEASE EXPLAIN
NOTICE OF NONDISCRIMINATORY POLICY AS TO STUDENTS--PATRICIAN ACADEMY ADMITS STUDENTS OF ANY RACE, COLOR, NATIONAL AND ETHNIC ORIGIN TO ALL THE RIGHTS, PRIVILEGES, PROGRAMS, AND ACTIVITIES GENERALLY ACCORDED OR MADE AVAILABLE TO STUDENTS AT THE SCHOOL. IT DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL AND ETHNIC ORIGIN IN ADMINISTRATION OF ITS EDUCATIONAL POLICIES, ADMISSIONS POLICIES, SCHOLARSHIP AND LOAN PROGRAMS, AND ATHLETIC AND OTHER SCHOOL-ADMINISTERED PROGRAMS.