St. Michael’s Academy

NewStudentApplication

For the academic year beginning September, 2018

(Please complete this form in black ink.)

Student Information

Please circle the GRADE for which you wish to apply: PreK-3PreK-4 K12345678

*Age child must be by October 1, 2018. *3*4 *5

Last NameFirst NameMiddle Name

Gender (check one): □ Male □ Female Name you wish your child to be called:

Street Address (P.O. Box, if applicable)CityStateZip Code

Mailing Address (if different from Street Address)CityState Zip Code

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Home Phone NumberDate of Birth: MM/DD/YYPlace of Birth (City / Country)

ReligionParish / ChurchCity and State

Baptized: □ Yes □ No //

If yes, please supply Baptismal Record Baptism DateParish where Baptism took placeCity / Country

1st Communion: □Yes□No //

1st Communion DateParish where 1st Communion took placeCity / Country

School(s) Previously Attended:

Name of SchoolCityStateDates AttendedGrade(s) Attended

Name of SchoolCityStateDates AttendedGrade(s) Attended

If additional space is needed to list schools previously attended, please use a separate sheet of paper.

The response to the following item is not required; however, your assistance with this information is highly encouraged:

Race (please check one): □Caucasian□African-American□Asian□Hispanic□Other:

St. Michael’s Academy will admit students of any race, color, nationality or ethnic origin to all rights, privileges, programs and activities generally accorded or made available to students in the Academy.

** May we include your family information (name, student name, address and phone number) in our student directory? Yes____ No _____

Family Information

Please list all siblings who now attend, or who have attended,St. Michael’s Academy, from oldest to youngest:

Name (First and Last) / Grade / Age / Gender
M=Male; F=Female / St. Michael’s Academy Graduate (year)

St. Michael’s Academy Application – page 2 of 4

Mother/Guardian:

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Last NameFirst NameHome Telephone

Street Addressif different than student City State Zip Code

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OccupationE-Mail AddressCell Phone

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Place of EmploymentCity and StateWork Telephone

ReligionParish / ChurchCity and State

Father/Guardian:

()

Last NameFirst NameHome Telephone

Street Address if different than studentCityStateZip Code

()

OccupationE-Mail AddressCell Phone

()

Place of EmploymentCity and StateWork Telephone

ReligionParish / ChurchCity and State

Grandparent Information:

()

Maternal GrandmotherE-mailHome Telephone

Street AddressCityStateZip Code

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Maternal GrandfatherE-mailHome Telephone

Street AddressCityStateZip Code

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Paternal GrandmotherE-mailHome Telephone

Street AddressCityStateZip Code

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Paternal GrandfatherE-mailHome Telephone

Street AddressCityStateZip Code

Student lives with: (Please check one)

 Mother & Father Mother Father  Mother & Stepfather  Father & Stepmother  Other:

What is the primary language spoken at home: ______

Name of Student’s Legal Guardian (if applicable):

Last NameFirst Name

Name of Student’s Stepparent (if applicable):

Last NameFirst Name

St. Michael’s Academy Application – page 3 of 4

Preschool Schedule Selection (for Preschool Applicants only):

All preschool students must be potty trained before the school year begins.Please check the class schedule you wish for your child.

Option 1: 4-Year-Olds (must be 4 by Oct. 1) / □5 Full Days: Mon.-Fri. / Do you plan to continue your child’s education at St. Michael’s after Preschool? □Yes □No
Option 2: 3 and 4-Year-Olds (must be 3or 4 by Oct. 1) / □5 Full Days: Mon.-Fri. / □ 3 Full Days:
M/W/F / □ 2 Full Days: Tues/Thurs
Student Medical and Emergency Information

Emergency Contacts (other than child’s parents or guardians):

()

Full NameRelationshipArea Code & Phone Number

Street Address (P.O. Box, if applicable)CityStateZip Code

()

Full NameRelationshipArea Code & Phone Number

Street Address (P.O. Box, if applicable)CityStateZip Code

Medical

Physician’s NameAddressCityStateArea Code & Phone Number

Dentist’s NameAddressCityStateArea Code & Phone Number

Name of Policyholder (Medical Insurance)Name of Insurance CompanyPolicy #

If you do not have medical insurance, the Diocese of Springfield requires that you purchase school accident insurance.

Does your child have any food allergies (dairy, peanuts, etc.)? □Yes □No If yes, please list

Does your child have allergic reactions (bee stings, etc.)? □Yes □No If yes, please list

Does your child take medications on a daily basis? □Yes □No If yes, please list

Does your child require that medication be administered during school hours? □Yes □No If yes, please list

Does your child require special education services? □Yes □No If yes, please list

Are your child’s immunizations up to date? □Yes □No

*Providingproof of updated immunization records is required before admission to St. Michael’s Academy is considered complete. New students must undergo a physical examination within the first 12 months of being accepted. Students entering Kindergarten, Grade 4 or Grade 7 must show proof of a physical before the new school year begins.

St. Michael’s Academy Application – page 4 of 4

General Information

How did you hear about St. Michael’s Academy?

What most influenced your decision to enroll your child?

______

What do you hope your child will gain from this experience?

Is there any additional information that can help us in the classroom?

Please list immediate family members who are Catholic school alumni/ae in the Diocese of Springfield:

Last NameMaiden Name (if applicable)First NameSchoolYears Attended

AddressCityStateZip Code

Last NameMaiden Name (if applicable)First NameSchoolYears Attended

AddressCityStateZip Code

St. Michael’s Academy Agreement

In order to enhance the academic and extracurricular experiences of every child enrolled at St. Michael’s Academy, we must work together as parents, students, and school personnel. As members of the St. Michael’s Academy community, you and your parents/guardians agree to:

  1. support and encourage the Catholic-Christian Gospel values that are central to the philosophy and mission of St. Michael’s Academy;
  2. abide by rules and regulations detailed in the Parent/Student Handbook;
  3. perform academically to the best of your ability and complete all assignments on time;
  4. respect all school personnel and students;
  5. understand the importance of being present at school on a daily basis and arriving on time.

With our signatures, we agree to follow the terms listed above in the St. Michael’s Academy Agreement. We understand that this contract is real and will be enforced. St. Michael’s Academy reserves the right to amend this Agreement.

Student Signature (required for Grades 1-8)Parent/Guardian SignatureDate