Cardinal Lacroix Academy Online Registration

DIOCESE OF MANCHESTER
Catholic School Registration
Date:

MonthDayYear
Date
Please print or type all information
School Name:
City/Town
MaleFemale
Preferred Phone Number
Student First Name
Student Middle Name
Student Last Name
Address: Street
Address: City/State/Zip
Date of Birth

MonthDayYear
Date
Current Grade
Registering for Grade:
Present School Name and Address:
Student's Religion:
Parish name and town:
YesNo
Date of Baptism:

MonthDayYear
Date
Parish:
City/Town:
Date of First Reconciliation

MonthDayYear
Date
Parish:
City/Town:
Date of First Eucharist

MonthDayYear
Date
Parish:
City/Town:
YesNo
Name :
Grade
Name :
Grade
Grade
The following statistical information is for reporting purposes and will not be used in a discriminatory manner:
YesNoAmerican Indian/NativeAsianBlack/African AmericanNative Hawaii/Pacific IslandWhiteTwo or more racesUnknown
CatholicNon Catholic
YesNo
If yes, please specify
MEDICAL INFORMATION
YesNo
If yes, please list the condition(s) or allergy
Please list any special instructions related to the condition(s)
YesNo
YesNo
Students carrying an inhaler or epi-pen must complete a separate form.
YesNo
If yes, please list the medications and dosages:
Medication
Dose
Medication
Dose
Medication
Dose
All medications must be presented in the original bottle with the prescription label and must be held in the health office.
Student's Physician
Phone Number
Student resides with: (please check all that apply)
FatherMotherStepfatherStepmotherGuardianMarriedSeparatedDivorcedNever MarriedWidowedOther
FatherMotherBothOther
FatherMotherBothFatherBothOther (please specify)If never married, divorced or separated, who has primaryOther
FatherMotherBothFatherBothOther (please specify)If never married, divorced or separated, who has primaryOther
Please provide a copy of any relevant court orders, such as Parenting Plan, Final Divorce Decree, or Guardianship Order. The orders will be maintained in the student's file.
Both parentsFather onlyMother onlyOther (please specify)
Dr.Mrs.Ms.Other
LivingDeceased
Name:
Maiden Name
Home Address:
Cell Phone:
E-mail:
example@example.com
Employer:
Title:
Business Address:
Business Phone:
Dr.Mr.Other
Name:
LivingDeceased
Home Address (if different from above)
Cell Phone:
E-mail:
example@example.com
Employer:
Title:
Business Address:
Business Phone:
If this student is under the care of a guardian, please attach Addendum A.
TUITION/FINANCIAL RESPONSIBILITY
Dr.Mr.Mrs.Ms.Other
Name:
Maiden Name
Relationship to Student:
Home Address:
Cell Phone:
E-mail:
example@example.com
Employer:
Position:
Business Address:
Business Phone:
EMERGENCY CONTACT INFORMATION
Please list other persons authorized to care for the student if parents/guardians cannot be reached.
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
The people named above have agreed to accept responsibility for my child if I cannot be reached in case of emergency during the school day. I understand that it is my responsibility to advise the school office if this information changes during the school year.

We certify that all information submitted in the registration process, including supporting materials, is factually accurate and honestly presented. I understand that if such information is inaccurate or false, the student's admission may be revoked. We agree to update any information if it becomes outdated.
Signature of Parent:
Signature of Parent:
Registration Fee (if applicable)Baptismal CertificateHealth FormCustody Documents (if applicable)
Other information:
Received by:
Date:

MonthDayYear
Date
Should be Empty:

DIOCESE OF MANCHESTER

Catholic School Registration

MEDICAL INFORMATION

TUITION/FINANCIAL RESPONSIBILITY

EMERGENCY CONTACT INFORMATION