Student Information

South Hills Catholic Academy Registration Form - Additional Student

Please Use This Form To Register Each Additional Student From The Same Family
The following are required for Registration at South Hills Catholic Academy to be complete:
- Birth Certificate
- Baptismal Certificate
- Immunization Record
- Registration Form for Each Student
- Catholic School Parents Memorandum of Understanding (found here )
- Tuition and Family Share Agreement
- Records Release Form if Applicable (found here )
- Home Language Survey (found here )
- Publicity Authorization Form (found here )
- Non-Refundable Registration Fee of $100 per Family
Student Information
Student's Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Ethnicity

African American Asian Caucasian Hispanic Multi-Racial Native American Pacific Island Other
Gender *
Birth Date *

Month Day Year
Date
Age as of September 1 *
Entering Grade *

4 Year Old Preschool (Half Day) WAITLIST ONLY 4 Year Old Preschool (Full Day) WAITLIST ONLY Kindergarten (WAITLIST ONLY) First Grade Second Grade Third Grade (WAITLIST ONLY) Fourth Grade Fifth Grade Sixth Grade Seventh Grade (WAITLIST ONLY) Eighth Grade (WAITLIST ONLY)
Transportation *

Car Rider Bus Rider Walker After School GAP
Religion *
If Catholic, Include Parish and Diocese Names *

Sacramental Information of Student

	Check if Received	Date Received	Church Name and Address
Baptism
Reconciliation
Holy Eucharist
Confirmation

Public School District of Residence (Taxes Paid To) If Different Than Student #1

Baldwin Whitehall Bethel Park Brentwood Chartiers Valley City of Pittsburgh Keystone Oaks Mt. Lebanon Peters Township South Park Upper St. Clair Other
Public School Building Student Would Otherwise Attend *
Current School (If Applicable)
Address of Current School

Street Address

Street Address Line 2

City State

Zip Code
Parent / Guardian Information
Parent / Guardian #1 Name *

First Name Last Name
Relationship To Child *
Parent / Guardian #1 Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent / Guardian #1 Email Address *
example@example.com
Parent / Guardian #1 Home Phone Number
Parent / Guardian #1 Cell Phone Number *
Parent / Guardian #1 Work Phone Number
Please enter a valid phone number.
Parent / Guardian #1 Employer and Occupation
Parent / Guardian #1 Religion
Parent / Guardian #1 Parish Where Registered
Is Parent / Guardian #1 a Catholic School Alumni?

Yes No
Parent / Guardian #2 Name

First Name Last Name
Relationship To Child
Parent / Guardian #2 Address

Street Address

Street Address Line 2

City State

Zip Code
Parent / Guardian #2 Email Address
example@example.com
Parent / Guardian #2 Home Phone Number
Please enter a valid phone number.
Parent / Guardian #2 Cell Phone Number
Please enter a valid phone number.
Parent / Guardian #2 Work Phone Number
Please enter a valid phone number.
Parent / Guardian #2 Employer and Occupation
Parent / Guardian #2 Religion
Parent / Guardian #2 Parish Where Registered
Is Parent / Guardian #2 a Catholic School Alumni?

Yes No
Student Resides With *

Both Parents Father Only Mother Only Joint Custody Other
Emergency Contacts
EMERGENCY CONTACTS MUST BE SOMEONE OTHER THAN PARENT / GUARDIAN
Emergency Contact 1
Name *

First Name Last Name
Relationship To Child *
Phone Number *
Emergency Contact 2
Name *

First Name Last Name
Relationship To Child *
Phone Number *
Physician and Medical Information
Primary Care Physician's Name *

First Name Last Name
Primary Care Physician's Phone Number *
Preferred Hospital
Please List Any of the Following: Current Medications, Medication Allergies, Food Allergies, Chronic Health Concerns. *
In Order To Provide The Best Education For Your Child, Please Answer The Following Questions:
Has Your Child Ever Had a Psychological Examination? *

Yes No
Has Your Child Ever Been Diagnosed with a Learning Disability by a Physician? *

Yes No An Evaluation is in Progress
If Yes, What is the Diagnosis?
Has Your Child Ever Received Any of the Following Services? *

No Project DART Counseling Remedial Math Emotional Support Remedial Reading Gifted Support Speech /Language Learning Support Other
Has Your Child Ever Had an IEP? *

Yes No
If Yes, Please Indicate the Disability and Submit a Copy of the IEP to the School Office.
Has Your Child Ever Been Diagnosed with a Medical Condition that the School Should be Made Aware Of? (If Yes, Please Explain in the "Other" Section.) *

Yes No Other
Has Your Child Ever Repeated a Grade? (If Yes, Please Explain Which Grade and Why in the "Other" Section.) *

Yes No Other
Has Your Child Ever Received a Suspension from School? (If Yes, Please Explain in the "Other" Section.) *

Yes No Other
Has Your Child Ever Been Asked to Transfer? (If Yes, Please Explain in the "Other" Section.) *

Yes No Other
Been Expelled from School? (If Yes, Please Explain in the "Other" Section.) *

Yes No Other
Please Sign and Submit Form
Please sign here. After signing, you must hit SUBMIT to complete the registration process. *

Clear
Should be Empty:

South Hills Catholic Academy Registration Form - Additional Student

Student Information

Parent / Guardian Information

Emergency Contacts

Physician and Medical Information

In Order To Provide The Best Education For Your Child, Please Answer The Following Questions:

Please Sign and Submit Form