Registration Form
Preschool 3/4 : 3 day o or 5 day o K o 1 o 2 o 3 o 4 o 5 o 6 o 7 o 8 o Date of Registration ____________
STUDENT INFORMATION
Student’s Legal Name:______
First Middle Last Nickname
Street Address: ______City: ______Zip Code: ______
Mailing Address (if different from above): ______
Phone Number: ______E-mail (to be used for school communication): ______
Public School District in which student resides: ______County of Residence: ______
Birthdate: _____/______/______Birthplace City/St : ______Gender: ______Age: ______
Month Day Year
U.S. Citizen: oYes oNo Native Language: ______Religion/Parish Registered:______
Race (Check One):
o Asian
o Black
o American Indian or Alaskan Native
o White
o Native Hawaiian or Pacific Islander
o Multi-Racial / Ethnicity (Check One):
o Hispanic Origin
o Not Hispanic Origin
/ Sacramental Information (List Date and Church):
Baptism: ______
Eucharist: ______
Penance: ______
PARENTS AND/OR GUARDIANS
Student Resides With: o Both Biological/Adoptive Parents o Father Only o Mother Only o Grandparents
o Father/Stepmother o Mother/Stepfather o Foster Family o Guardian o Other ______
Marital Status of Parents: o Single o Married o Separated o Divorced o Remarried o Widowed
*If Divorced, Remarried, Separated or Single, please indicate who is responsible for the tuition for the student(s)?
o Father ____% Name______o Mother ____% Name______o Other ____% Name______
Biological/Adoptive Parent Information (required)
Mother’s Name: ______Lives with Student: oYes oNo
First Middle Last Maiden
Mailing Address (if different): ______
Street City State Zip
Phone Numbers: Home: ______Work: ______Cell: ______E-mail: ______
Place of Employment/Occupation: ______Religion/Parish Registered:______
Spouse (if applicable): Name:______Phone Numbers: Work: ______Cell: ______
Father’s Name:______Lives with Student: oYes oNo
First Middle Last
Mailing Address (if different): ______
Street City State Zip
Phone Numbers: Home: ______Work: ______Cell: ______E-mail: ______
Place of Employment/Occupation: ______Religion/Parish Registered:______
Spouse (if applicable): Name:______Phone Numbers: Work: ______Cell: ______
If the student is NOT living with both parents, is there a temporary or permanent custody order/decree allocating parental rights and responsibilities? o Yes o No If yes, a certified copy of the custody order must be provided yearly.
Would the non-custodial/non-residential parent like to receive school correspondence? o Yes o No
Legal Guardian/Foster Parent/Grandparent/Other Information (if applicable)
Name:______Lives with Student: oYes oNo
First Middle Last
Mailing Address (if different): ______
Street City State Zip
Phone Numbers: Home: ______Work: ______Cell: ______E-mail: ______
If the student is placed with a legal guardian/foster parent or residing with a grandparent(s), legal documents which declare placement must be provided to the school.
Revised 09/16 (over)
ALTERNATE EMERGENCY CONTACT (Other than Parents)
In case of emergency or school closure, please provide us with names, addresses and phone numbers of contacts if the school cannot contact you. (Must be local)
Emergency Contact #1
Name / Relationship to student / Approved
Pick-Up (Y/N) / Address / Phone Numbers
*Please indicate if Home(H)/Cell(C)/Work(W)
Emergency Contact #2
Name / Relationship to student / Approved
Pick-Up (Y/N) / Address / Phone Numbers
*Please indicate if Home(H)/Cell(C)/Work(W)
NEW STUDENTS ONLY
Name of School: ______Grade Level at Transfer: ______
Address: ______
Street City State Zip
Phone Number: ______Fax Number: ______
Is this child currently receiving any special education programs or services: o Yes o No
If Yes, please check the following:
o Autism o CD - Cognitive Disability o Deafness - Hearing Impairment o ED – Emotional Disturbance
o MD – Multiple Disabilities o OH – Orthopedic Handicap o OHI – Other Health Impaired
o SLD – Specific Learning Disability o Speech/Language o TBI – Traumatic Brain Injury
o VI – Visually Impaired
Is this child currently on a 504 Plan: o Yes o No
Does this child have an IEP: o Yes o No
Has this child had an IEP in the past: o Yes o No
Has this child been referred for a speech, hearing, orthopedic or cognitive evaluation at any time in the past: o Yes o No
Please let us know how you heard about our school:
Are there any unpaid fines or fees at your child’s previous school? o Yes o No
Has this student previously attended Immaculate Conception School? o Yes o No
A COPY OF STUDENT BIRTH CERTIFICATE OR VISA/IMMIGRATION DOCUMENTATION IS REQUIRED FOR ALL STUDENTS.
FOR OFFICE USE ONLY
___ Birth Certificate ___ Immunization Record
___ Baptism Certificate ___ Emergency Card
___ Proof of Custody ___ Record Transfer ___Option C /
___ Registration Fee Paid
___ Cash ___Check:#:______
Revised 09/16
Immaculate Conception School admits students of any race, color, national and ethnic origin to all 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.