Lima Central Catholic High School 2020-2021 Application Form

Lima Central Catholic High School

2020-2021 Application Form
Date:

Month Day Year
Date
Student Information
What grade will your student be entering Fall of 2020?

9th 10th 11th 12th
Student Name

First Name Middle Name Last Name
Birthdate:

Month Day Year
Date
Birthplace (City, State, Country):
Address

Mailing Address

Street Address Line 2

City

Zip County
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Social Security Number:
Gender

Male Female
Preferred T Shirt Size
Ethnicity:

White Black/African American Multiracial Hispanic Asian Indian/Alaskan
School Now Attending:
Public School District:
Is your student an EdChoice Scholarship Recipient?

Yes No Unsure
Is your student a Jon Peterson/Autism Scholarship Recipient?

Yes No Unsure
Is your student on any educational plan? If yes, please plan to provide a copy

Yes, a 504 Plan Yes, an IEP Yes, a Service Plan Yes, IMap No Unsure
Has the applicant ever been found responsible for a disciplinary violation at school, whether related to academic misconduct or behavioral misconduct, that resulted in the applicant's probation, suspension, removal, dismissal, or expulsion from school?

Yes No
If yes, please explain the violation here or let us know if you would like to discuss this over the phone?
PARENT/GUARDIAN INFORMATION
Parent Guardian I
Relation To Student

Natural Mother Natural Father Custodial Mother Custodial Father
Name

Prefix First Name Middle Name Last Name
Maiden Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Place of Employment
Email Address
example@example.com
Cell Phone
Work Phone

Area Code Phone Number
Home Phone
Are you Catholic?
Catholic? (This will not impact our enrollment decision)

Yes No
Name of Parish (If Catholic)
Parent Marital Status
Alumni of LCC?

Yes No
Graduation Year (If LCC Alumni)
Parent Guardian II
Relation To Student

Natural Mother Natural Father Custodial Mother Custodial Father
Name

Prefix First Name Middle Name Last Name
Maiden Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Place of Employment
Email
example@example.com
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Catholic? (This will not impact an enrollment decision)

Yes No
Name of Parish (If Catholic)
Parent Marital Status
Alumni of LCC?

Yes No
Year of Graduation (If LCC Alumni)
LEGAL CUSTODY
Student Lives with:

Both Natural Parents Mother as Custodial Parent Father as Custodial Parent Grandparent(s) with legal custody
If separated/divorced please indicate the primary custodian of the student:
(Please provide complete supporting documentation for the following when applicable: Agreed Judgment Entry: Custody and Support, Judgment Entry Decree of Divorce, Judgment Entry Decree of Dissolution of Marriage, Shared Parenting Decree, Legal Guardianship, Custody Affidavit, Power of Attorney, Judgment Entry of Adoption)
Who is responsible for paying tuition and fees?
Would you like to receive information about tuition assistance?

Yes No
Please tell us how you learned about LCC:
PARENTAL STATEMENT OF INTENT: Why do you, the parents/guardians, want your son or daughter to attend Lima Central Catholic High School?
Should be Empty:

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Lima Central Catholic High School

PARENT/GUARDIAN INFORMATION

Parent Guardian I

Parent Guardian II