Application Capital Card Credit One Status - DOC by zkv45074

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									                                          APPLICATION FOR ADMISSION
                                           SCHOOL YEAR 2010-2011

          A non-refundable Application Fee of $100.00 per child must accompany the Application form.
      All checks should be made payable to Our Lady of Grace School. We accept Visa, Mastercard and American Express.


STUDENT INFORMATION

Grade Applying For:________Student’s Name:____________________________________________
                                                      Last        First       Middle
Date of Birth: ____/____/____Place of Birth: City ________________________State_______________
Gender: _________ Race:______________U.S. Citizen?_____________Catholic? (circle one) Yes No
Student’s Home Address: _____________________________________ Home Phone ( ) ___________
City: _________________________ State: ____________________ Zip Code: _________________

Baptism Date: _____________Church ____________________City/State_______________________
Reconciliation Date: _________ Church ____________________City/State _______________________
First Communion Date: ________Church____________________City/State_______________________
Confirmation Date: __________Church ____________________City/State_______________________

FAMILY INFORMATION – COURT DOCUMENTS ARE REQUIRED FOR ALL LEGAL CUSTODY CASES

If Catholic, We are registered in_____________________________________________________Parish

Mother’s Name: _________________________________________ Marital Status_________________
                     Last          First      Maiden
Mother’s Address: _________________________Home Phone ( )      E-Mail:____________________
Place of Birth: __________________________________________ Religion: ____________________
Place of Employment: ___________________________ Work ( )________Cell (__)_________________

Father’s Name: _________________________________________ Marital Status _________________
Father’s Address: __________________________Home Phone (__)________E-Mail:_________________
Place of Birth: __________________________________________ Religion: ____________________
Place of Employment: ___________________________ Work (__)_______ Cell (__)_________________

List below names of other siblings in the family and their birth dates: ___________________________________
_____________________________________________________________________________
                                                   (complete other side)
SCHOOL INFORMATION

Name of School/Pre-School/Day Care: _____________________________________ Grade: ___________
                                                      Present/Last Attended
School Address: __________________________________________________________________
                              Street                                 City                   State          Zip Code
Teacher’s Name: _________________________ Principal’s/Director’s Name: _______________________
School Phone (__)____           Fax ( )__________Reason for Transfer_____________________________
Has student ever been suspended or dismissed from school for academic, disciplinary, or other reasons? If yes, give
date and reason_________________________________________________________________
Has student ever been referred to anyone for academic evaluation/testing; psychological evaluation/testing? If yes,
please provide a copy of the report/recommendations at time of application.
What public school would student attend if he/she were not attending this school? _________________________
Has student previously attended Our Lady of Grace School? ___________ If yes, when? ___________________

STUDENT HISTORY

Health Insurance Company’s Name: _____________________________________Policy#______________
Insurance Company Address: ____________________________________________________________
Has student any health/physical needs? ___________ If yes, describe: ________________________________
If your child has food allergies, please list ____________________________________________________
List daily medications: ________________________________________________________________
If your child is applying for Pre-Kindergarten, is your child potty trained? (circle one) yes no

PAYMENT INFORMATION

Name and address of person(s) who will be responsible for payment of student’s tuition and/or the Triad Catholic Schools
Capital Fee______________________________________________________________________
List any special instructions regarding student, tuition, guardianship, etc. which will help us to assist the family: _________
_____________________________________________________________________________
Were you referred to Our Lady of Grace School by another school family? If so, please print their name and address:
____________________________________________________________________________
How did you initially hear about us? ______________________________________________________


_________________________________                                              ___________________________
       Parent/Guardian Signature                                                           Date



For Office Use Only -
Date __________Check #__________Cash _______Credit Card________________Amount$_______________
10/22/09

								
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