Online Application

Application for Grade:*

Date

Child's Name*

First Last

Gender*

Male
Female

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Place of Birth*

Home Phone

Home Email*

Parent's Cell Phone*

Ethnicity

Caucasian
African American
Hispanic
Asian
Other

Student resides with:*

Both Parents
Mother Only
Father Only
M/Stepfather
F/Stepmother
Guardian

Name of Step Father/Mother or Guardian if applicable:

Religion*

Enter N/A if none.

Home Parish & Location*

Baptismal Church, Date, Location*

1st Communion Church, Date, Location*

Confirmation Church, Date, Location*

Extenuating Parental Circumstances:

Father Deceased
Mother Deceased
Parents Separated
Parents Divorced

Is a language other than English spoken at home? If "YES", what language?

Doest the student most frequently speak a language OTHER than English? If "YES", what language?

Does the student have a first language OTHER than English? If "YES", what language?

Parent & Family Information

Father's Full Name*

First Last

Occupation*

Business Phone

Name of Company

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email

Mother's Full Name

First Last

Occupation

Business Phone

Name of Company

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email

School Last Attended

(if applicable)

School Last Attended

Grade Last Attended

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Does your child have a current IEP? If "YES", please describe the nature of the testing.

Does your child already have siblings attending St. Elizabeth Seton Catholic Church or a sibling who will be enrolled with him/her?

Yes
No

If "YES", please list the names and grades below:

Name & Grade Level:

Is there anyone other than the parent or guardian who will be picking up your child regularly, please list their names and relationships below:

Medical Information

Child's Doctor

Prefix First Last

Phone

Other Emergency Contact & Relationship*

First Last

(other than parents, in case of an emergency)

Phone

Other Emergency Contact & Relationship*

First Last

(other than parents, in case of an emergency)

Phone

Is your child taking any medications. If "YES", please list below.*

Yes
No

Names and Purpose of Each Medication

Has your child ever had:

Measles
Mumps
Chicken Pox
Convulsions
Diabetes
Allergies
Meningitis
Whooping Cough

Does your child have:

Hearing Loss?
Speech Disabilities?
Learning Disabilities?

Does your child have any physical handicaps, allergies or other conditions that might affect his/her school work, or that we should know about in order to respond correctly should an incident arise? If "YES", please explain.*

Yes
No

Further explanation:

Parent & Family Information

School Last Attended

Medical Information

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