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St. Rose of Lima Catholic School Student Admission Application 2015-2016

* = required field

APPLICANT INFORMATION

Applicant Name (person submitting application)*

Applicant Email*

Applicant Phone Number*

STUDENT INFORMATION

Student Name*

Date of Birth*

Address*

City/Zip*

Gender*
MaleFemale

Race*
American Indian/Native AlaskanAsianBlackNative Hawaiian/Pacific IslanderWhite2 or more Races

Student's Religious Affiliation*

Church Attending*

Parent Information*
MarriedSeparatedDivorcedDeceased (Father and/or Mother)

Student lives with*
Both ParentsFatherMotherOther

If you checked Other above, list who student lives with below:

FATHER'S INFORMATION

Father's Name*

Father's Relationship*
Natural/AdoptiveStepfatherGuardian

Father's Address (if different)

Father's Email*

Father's Employer*

Father's Occupation*

Father's Religion/Church Attending*

MOTHER'S INFORMATION

Mother's Name*

Mother's Relationship*
Natural/AdoptiveStepmotherGuardian

Mother's Address (if different)

Mother's Email*

Mother's Employer*

Mother's Occupation*

Mother's Religion/Church Attending*

SIBLING INFORMATION

Sibling #1 Name

Sibling #1 Relationship

Sibling #1 Age/Grade

Sibling #2 Name

Sibling #2 Relationship

Sibling #2 Age/Grade

Sibling #3 Name

Sibling #3 Relationship

Sibling #3 Age/Grade

Sibling #4 Name

Sibling #4 Relationship

Sibling #4 Age/Grade

ACADEMIC INFORMATION

If your child has been or is currently enrolled in school, please tell us where so that records may be requested.

If your child has been referred for testing, has been tested, or is currently participating in a Special Education program, please tell us where and when so that records may be requested.

Has your child ever been expelled from school?*
YesNo

If yes, when and where?

HEALTH INFORMATION

Please list any health problems of which the school should be aware such as medications, physical challenges, visual/hearing difficulties, ADD/ADHD, asthma, etc.

AGREEMENT

By signing this form, I do hereby agree to accept all guidelines set forth by St. Rose of Lima School. I further understand that if my child is accepted, he or she will be expected to follow all the policies of St. Rose School and the Archdiocese of Indianapolis. I also understand that violation of said rules and regulations will be dealt with in accordance to established school and Archdiocesan policies. These guidelines are in effect for all students attending St. Rose of Lima School. We reserve the right to cancel the registration of this student for reason of deficiency in scholarship, unsatisfactory conduct, or any other just cause. I agree to accept the obligation of meeting tuition payments and payments of other regular fees in accordance to school policy for each period of enrollment.

I agree to St. Rose’s Medication Policy, Internet Policy, and Code of Conduct.

I agree that my child’s image and/or work may be used for promotional purposes and marketing unless I provide written notification to the school office.

This application will not be considered final until confirmation is received from the previous school (if applicable) that all financial obligations are current.

Signature of Parent/Guardian (type your full name as your signature)*

Date*