Office Use Only Application # Date Received Registration Fee Date of Registration Birth Certificate Baptismal Certificate Health Records

REGISTRATION Saint Agnes School 2008–2009 Grades Pre-K – 8 Grade

All of the following must accompany this form. Please check (P) to indicate you have attached each item. Registration fee ($150) Birth certificate (We must see the original) Baptismal certificate Immunization Record: Current Report Card Most recent Standardized Test results

Student Information INCOMPLETE FORMS WILL NOT BE ACCEPTED

Name

Social Security #

-

-

First

Middle

Last

Suffix

Sex

Male

Female

Birth Information

Date of Birth

U.S. Citizen?

Yes

No

City

State

(mm/dd/yyyy)

Address

Phone

Address line 1

Home

E-mail

Address line 2

City

State

ZIP

Parent/Guardian Information

Father’s name							Phone
	Title	First	Middle		Last	Suffix		Work
Occupation				Place
								Cell/Pager
Country of Father’s Birth							E-mail

Religion (check one)	Catholic	Orthodox		Non-Catholic	If non-Catholic, specify denomination:
If Catholic, in which rite?	Latin Church		Eastern Church (e.g., Ruthenian, Melkite Catholic, …)			Specify Rite:

Mother’s name							Phone
	Title	First	Middle		Last	Suffix		Work
Occupation				Place
								Cell/Pager
Country of Mother’s Birth							E-mail

Religion (check one)	Catholic	Orthodox		Non-Catholic	If non-Catholic, specify denomination:
If Catholic, in which rite?	Latin Church		Eastern Church (e.g., Ruthenian, Melkite Catholic, …)			Specify Rite:

Siblings
	Name	Date of Birth (mm/dd/yyyy)	School	Grade

Marital Status of Parents	Married	Separated		Divorced	If divorced, who has legal custody?
	Mother re-married		Father re-married			Mother deceased	Father deceased

Name of Step-parent or Guardian
	Title	First	Middle	Last