- - - - - Father/Mother Mother -

New
Student Application
20L4-1.5
S€$
Saint Charles Borromeo School
Grade Registering for:
Student:
l,ast
Female
Male
t-shirt
Religion
size
-Primary residence
City, State, Zip
P.O. Box/Address
Place of Birth
Date of Birth:
City
Kinderqarten child must be 5 on or before September 30 of vear applvinq to school
Items A-C are necessary for applicants seeking positions in grade 1-8.
A: Name of school your child is currently attending:
B: ls your child currently receiving any special services (remedial reading/math, speech, tutoring, etc.)?
lf yes, what services?
C. A signed Release of Records form
Guardian/Father:
First
Home
Phone
Cell Phone
Address:
Address:
P.O.
Parents
First
Box/Address
are:
Child resides
Single
with:
_
*
email address
City, State, Zip
P.O. Box/Street
Guardian/Mother:
City, State,
Married
Home
Phone
Cell Phone
Zip
email address
Separated
Divorced
- Mother Father/Mother
Father/Stepmother
Mother/Stepfather _
Custody ogreemenl must be provided.
Widowed
-Father
-
-Other
Fair Share" Program?
lf St. Charles, do you participate in the "My
Parish Affiliation:
You ore required
to notify school should moritol stotus or onv residences chonoe
Sacramental Data
.Baptism:
Reconciliation:
Eucharist:
Date
Parish
City
Date
Parish
City
Date
Parish
CitY
. A copy of your child's baptismal certificate must be turned in with registration
State
State
Applications for admission are reviewed upon receipt of allthe following items:
. Copy of most recent report card (1-8 only)
. Admission application
along with signed Release of Records form
o Bifih certificate (copy)
.
Copy of custody/guardian papers (if
. Baptismal cerlificate (copy)
applicable)
. School Health Questionnaire
.
Completed Permanent Record card
. Proof of residence (utility bill, etc.)
St. Charles School Admission Policy requires that Catholic families be registered in a Catholic parish; participate
in Mass every weekend; have a history of contributing a minimum of $10 in the weekly Church envelopes; and
be supportive of Catholic education and the policies of the school. School families are also required to
participate fully in our Parish Certificate Program (minimum of $5200/year).
Parent Signature
Date
New
S€S.
Student Application
2014-15
Saint Charles Borromeo School
HEALTH QUESTIONNAIRE
Child's Name:
First
Lasl
Birth date
Middle
Home Phone:
Address:
School last attended:
Parents'Names: Father
Guardian(s):
Family Physician:
Family Dentist:
City:
Mother
Office Phone:
Office Phone:
MEDICAL HISTORY:
1.
lmmunizations: Enter month/day/year of each immunization.
3_
2_
1_
Td
Booster:
Tdap or
32Potio: 1_
2MMR: 1Mumps
(if separate): Measles
32HIB: 13
2Hepatitis B: 1DPT:
1
Varivax (chicken pox): 1Other immunizations (Give type and date):
2.
44-
5
5
Rubella
4
2-
Has your child had any of the following?
Allergies/hay fever
Bee sting allergy
Diabetes
Eczema/hives
Nose bleeding
Asthma
Chicken pox
Ear infections
Epilepsy
Strep
3.
Any pertinent medical problems (i.e. hospitalization, serious injuries):
4.
Allergies: List all allergies affectin g the child and any special precautions or treatments
indicated for these allergies.
Date of exam
Wears olasses?
Speech problems?
Caos or tooth soacers?
Date of exam
Hearing loss?
Bowel or bladder elimination problems?
5.
Medications currently being administered to child:
Signature of parent:
Date:
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New
Student Application
S€S
20t4-15
Saint Charles Borromeo School
AUTHORIZATION FOR RELEASE OF SCHOOL INFORMATION
By my (our) signature below, I (we), as parent(s)/guardian(s)
of
DOB:
Name:
Address:
zip:
State:
City:
give permission to the principal of
(name of current school)
to release the following school records of
(name of student)
to St. Charles
Borromeo School:
* Grades and academic records
* Psychological assessments and records
* Disciplinary records
* Attendance records
* Medical records
* Test results and/or evaluations
* Response to lntervention (RTl) records
Based Measurement
-
DIBELS, AIMS web, STAR, Curriculum
Signature:
Relationship:
Signature:
Relationship:
P. 440-886-5546
F. 440-886-1163
"Travel the Poth to Achieve Excellence"
www.saintcharlesschool.org
7107 Wilber
Ave.
Parma, OH 44129