Pre-K Registration Form - St. John the Evangelist Catholic School

116 East Bishop Street, Bellefonte, PA 16823
Office: 814.355.7859 Fax: 814.355.2939
www.saintjohnsch.com
Welcome!
We are glad that you are considering St. John Catholic Pre-K for your child. Registration for the 2015-2016 school year
begins January 26, 2015 at 8:00 a.m., with priority given to those submitting a completed registration form by February
16, 2015.
St. John Catholic School Council has established that there will be a morning and afternoon Monday, Wednesday and
Friday 4-year-old class and a morning Tuesday and Thursday 3-year-old class.
The class size at St. John Pre-K is limited. In the likelihood that more than the allotted number of registrations is received
for Pre-K for a given year, the following criteria will be used to establish the class list:
1. Student currently enrolled in St. John Pre-K, or is a sibling of a St. John student or graduate;
2. St. John Parish member;
3. Member of another Catholic parish;
4. Other
If there are more registrants than space available in any of the categories above, date of submission of the registration
form will take priority to determine who is accepted into the class and the order on the waiting list.
Families will be notified on or before February 28 to inform them of their status in the 2015-2016 St. John Pre-K class.
A completed registration consists of the following:
 Completed Registration Form
 Non-refundable Registration Fee of $35 before September 1, 2015 or $75 after September 1, 2015
 Copy of Immunization Record
 Copy of Birth Certificate
St. John the Evangelist Catholic School ~ Achievement Focused. Faith Driven.
St. John Catholic School Registration Form 2015-2016
OFFICE USE ONLY:
Date Rec’d: _______________
PRE-K
116 East Bishop Street, Bellefonte, PA 16823
Office: 814.355.7859 Fax: 814.355.2939
www.saintjohnsch.com
__Registration Fee (Before 9/1=$35; After 9/1=$75)
__Copy of Birth Certificate retained
__Copy of Immunization Record retained
__Tuition Contract
Student Status (please check all that apply):
 Student currently enrolled in St. John Pre-K or is a sibling of a St. John student or graduate
 St. John Parish member
 Member of another Catholic parish
 Other
STUDENT INFORMATION
CLASS APPLYING FOR (must be age as of 9/1/2015)
 3 year old – Tues. & Thurs. (8:30 – 11:00 a.m.)
LEGAL LAST NAME
Please check preference for 4 year old class.
 4 year old – Monday, Wednesday & Friday (8:30 – 11:00 a.m.)
 4 year old – Monday, Wednesday & Friday (11:45 a.m. – 2:15 p.m.)
FIRST NAME
MIDDLE NAME
MAILING ADDRESS
CITY, STATE, ZIP
PHYSICAL ADDRESS (IF DIFFERENT)
CITY, STATE, ZIP
DATE OF BIRTH
PARISH OF MEMBERSHIP
BORO/TOWNSHIP
BIRTH PLACE / CITY, STATE, COUNTRY
GENDER
STUDENT RELIGION
STUDENT’S ETHNICITY Circle one:
HISPANIC
(This information is requested by the US Government, SJCS does not discriminate.)
STUDENT’S RACE Circle as applicable:
AMERICAN INDIAN/ALASKAN NATIVE
HAWAIIAN NATIVE/OTHER PACIFIC ISLANDER
(This information is requested by the US Government, SJCS does not discriminate.)
FAMILY INFORMATION Name, age or grade, school of other children in family.
NAME
GENDER
AGE or GRADE
NON-HISPANIC
ASIAN
WHITE
TWO OR MORE RACES
BLACK
SCHOOL ATTENDING
Student Name: ________________________________Page 2
PARENT / GUARDIAN INFORMATION Please list phone numbers in the order (A, B, C) they are to be called for contact.
PARENT / GUARDIAN NAME
EMAIL ADDRESS
EMPLOYER
OCCUPATION
RELIGION
EDU/DEGREE
PARISH
MAILING ADDRESS (If different from student)
CITY, STATE, ZIP
PHYSICAL ADDRESS (If different from mailing)
CITY, STATE, ZIP
PHONE A (Circle one: HOME
CELL
WORK)
PHONE B (Circle one: HOME
CELL
WORK)
PHONE C (Circle one: HOME
CELL
WORK)
RELATIONSHIP TO STUDENT Circle one:
FATHER
MOTHER STEP-PARENT GUARDIAN OTHER ____________________________
MARITAL STATUS Circle one:
MARRIED SINGLE
WIDOW
DIVORCED SEPARATED
SHOULD THIS PERSON RECEIVE SCHOOL MAILINGS AND EMAIL? Circle one: YES
NO
DOES THE STUDENT LIVE WITH THIS PERSON? Circle one:
YES
NO
SHARED CUSTODY
ARE THERE ANY LEGAL RESTRICTIONS? Circle one: YES
NO If YES, please attach court order / custody agreement.
PARENT / GUARDIAN NAME
EMAIL ADDRESS
EMPLOYER
OCCUPATION
RELIGION
EDU/DEGREE
PARISH
MAILING ADDRESS (If different from student)
CITY, STATE, ZIP
PHYSICAL ADDRESS (If different from mailing)
CITY, STATE, ZIP
PHONE A (Circle one: HOME
CELL
WORK)
PHONE B (Circle one: HOME
CELL
WORK)
PHONE C (Circle one: HOME
CELL
WORK)
CELL
WORK)
RELATIONSHIP TO STUDENT Circle one:
FATHER
MOTHER STEP-PARENT GUARDIAN OTHER ____________________________
MARITAL STATUS Circle one:
MARRIED SINGLE
WIDOW
DIVORCED SEPARATED
SHOULD THIS PERSON RECEIVE SCHOOL MAILINGS AND EMAIL? Circle one: YES
NO
DOES THE STUDENT LIVE WITH THIS PERSON? Circle one:
YES
NO
SHARED CUSTODY
ARE THERE ANY LEGAL RESTRICTIONS? Circle one: YES
NO If YES, please attach court order / custody agreement.
PARENT / GUARDIAN NAME
EMAIL ADDRESS
EMPLOYER
OCCUPATION
RELIGION
EDU/DEGREE
PARISH
MAILING ADDRESS (If different from student)
CITY, STATE, ZIP
PHYSICAL ADDRESS (If different from mailing)
CITY, STATE, ZIP
PHONE A (Circle one: HOME
CELL
WORK)
PHONE B (Circle one: HOME
CELL
WORK)
PHONE C (Circle one: HOME
RELATIONSHIP TO STUDENT Circle one:
FATHER
MOTHER STEP-PARENT GUARDIAN OTHER ____________________________
MARITAL STATUS Circle one:
MARRIED SINGLE
WIDOW
DIVORCED SEPARATED
SHOULD THIS PERSON RECEIVE SCHOOL MAILINGS AND EMAIL? Circle one: YES
NO
DOES THE STUDENT LIVE WITH THIS PERSON? Circle one:
YES
NO
SHARED CUSTODY
ARE THERE ANY LEGAL RESTRICTIONS? Circle one: YES
NO If YES, please attach court order / custody agreement.
PARENT / GUARDIAN NAME
EMAIL ADDRESS
EMPLOYER
OCCUPATION
EDU/DEGREE
RELIGION
PARISH
MAILING ADDRESS (If different from student)
CITY, STATE, ZIP
PHYSICAL ADDRESS (If different from mailing)
CITY, STATE, ZIP
PHONE A (Circle one: HOME CELL
PHONE B (Circle one: HOME CELL WORK)
PHONE C (Circle one: HOME CELL
WORK)
RELATIONSHIP TO STUDENT Circle one:
FATHER
MOTHER STEP-PARENT GUARDIAN OTHER ____________________________
MARITAL STATUS Circle one:
MARRIED SINGLE
WIDOW
DIVORCED SEPARATED
SHOULD THIS PERSON RECEIVE SCHOOL MAILINGS AND EMAIL? Circle one: YES
NO
DOES THE STUDENT LIVE WITH THIS PERSON? Circle one:
YES
NO
SHARED CUSTODY
ARE THERE ANY LEGAL RESTRICTIONS? Circle one: YES
NO If YES, please attach court order / custody agreement.
WORK)
Student Name: ________________________________Page 3
SCHOOLREACH EMERGENCY NOTIFICATIONS
Saint John Catholic School utilizes the SchoolReach Broadcast System for parent notification via automated phone calls. Calls are
generally for weather-related delays, dismissals or cancellations and other emergency purposes, but may be used any time it is
necessary to send a group message. Please provide phone numbers that you would like for us to use to call through this system.
Please list the numbers you would like to be called when using this system.
PHONE NUMBER 1
PHONE NUMBER 2
EARLY MORNING CALL
MID-DAY CALL
EVENING CALL
PHOTOGRAPHIC IMAGE AUTHORIZATION
I grant permission to St. John Catholic School and Parish in Bellefonte, Pennsylvania to use my child’s/children’s/youth’s name,
likeness, and/or photographic image in the production of the following: newspapers, newsletters, yearbooks, school website, school
social media, church bulletins, marketing brochures, radio, or television. I understand that if, for whatever reason, at any point in
time, I decide to revoke this agreement, and I so notify the Diocesan Office, Department, Parish, or School in writing, all references
to my child/youth (i.e., name, likeness, and/or photographic image) will no longer be used. I understand that web page references
and web page photographic images will be removed within thirty (30) days of the written notification. I understand that the
Diocesan Office, Department, Parish, or School is not responsible for access to the internet information or downloads made by users
using the web prior to this removal of web references (i.e., name, likeness, and/or photographic image). I further understand that
my child’s / children’s / youth’s name, likeness, and/or photographic image may continue to be used in any publication already
printed or published prior to my revocation of the consent provided herein.
______________________________________________________________
Name of Child (Please Print)
________________________________
Date of Birth
______________________________________________________________ _________________________________
Signature of Parent/Guardian
Date
AGREEMENT
The undersigned agrees that they and their child will abide by the policies and procedures that may be adopted from time to time by
the Diocese of Altoona-Johnstown or by St. John Catholic School, particularly those set forth in the school’s handbook and the
following agreement:
AS A MEMBER OF A CATHOLIC SCHOOL IN THE DIOCESE OF ALTOONA-JOHNSTOWN
As a parent/guardian of a student in a Catholic school, I understand, affirm and support the following:
1. The primary purpose of a Catholic school education is to form students in the values of Jesus Christ and the teachings of the
Catholic Church.
2. Catholic schools are distinctive religious education institutions operated as programs of the Catholic Church; they are not
private schools but are administered and supported by the sponsoring parish9es) or the diocese.
3. Attending a Catholic school is a privilege, not a right.
4. While academic excellence and involvement in extracurricular activities (i.e. sports, clubs, etc.) are important, fidelity to the
Catholic identity of the school is the fundamental priority.
5. The school and its administration have the responsibility to ensure that Catholic values and moral integrity permeate every
facet of the school’s life and activity.
6. In all questions involving faith, morals, faith teaching, and Church law, the final determination rests with the diocesan
bishop.
As a parent/guardian desiring to enroll my child in a Catholic school, I accept this agreement. I pledge support for the Catholic
identity and mission of this school and by enrolling my child I commit to myself to uphold all the principles and policies that
govern a Catholic school.
Father Signature ____________________________________________________________ Date ________________
Mother Signature ___________________________________________________________ Date ________________
Student Name: ________________________________Page 4
STUDENT HEALTH / OTHER HISTORY
Please check and sign
 YES, I give permission for information in this section to be communicated to school personnel, as necessary, in a
confidential manner.
 NO, I am intentionally leaving this section blank and request a private meeting to discuss the health of my child.
________________________________________________________________
Parent/Guardian Signature
Child’s Physician
Child’s Dentist
____________________________________
Date
Please check
YES
NO
Allergies
Please check as needed.
 Asthma
 Seasonal or Environmental Allergies
 Hay Fever
 Eczema
 Insect Allergies/Reactions LIST:
 Medication Allergies LIST:
 Food Allergies LIST:
Allergic Symptoms
Please check all that apply. Circle the first symptom usually experienced by your child.
 Hives
 Overall Swelling
 Tightness in Chest
 Itching
 Difficulty Talking/Breathing
 Shock
 Anxiety
 Difficulty Swallowing
Write the time that elapses before
 Pulse
onset of symptoms:
 Dizziness
 Wheezing
___________________________
 Confusion
 Abdominal Pain
 Other:
Current Medications
(other than vitamins)
Medication Names and Reason Needed:
Special Health Care
Has your child ever undergone any special test for health problems?
Has your child ever been seen by a specialist?
Is s/he currently under the care of a specialist?
Does your child have a poor appetite?
Does your child eat too much?
Does your child have excessive thirst?
Does your child have sleep problems?
Does your child have too much energy?
Does your child have too little energy?
Does your child have any physical restrictions?
Do you think your child should be doing more than s/he is doing for her/his age?
Please list concerns (or attach separate paper)
General
Student Name: ________________________________Page 5
Is your child toilet trained?
Circle one:
NO
YES
Does your child have any special fears?
Circle one:
NO
YES If YES, please explain.
Has your child gone to preschool or daycare before? Circle one:
NO
YES If YES, was it a positive experience?
Does your child wear (please circle, if applicable)
GLASSES
HEARING AID(S)
Does your child have any physical restrictions?
Circle one:
NO
DENTURES
OTHER (please explain)
YES If YES, please explain.
Does your child have any other health problems or behavior problems that need to be discussed with Pre-K Director?
Circle one: NO
YES If YES, we will contact you directly.
How did you find out about St. John Catholic Pre-K? Circle one
St. John Pre-K Student
Local News Publication
Friend
Other:
Briefly state your reason for enrolling your child at St. John Catholic Pre-K:
What do you hope that your child gains from their Pre-K experience?
Church Bulletin