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) 4 Year Old Preschool (Full Day) Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade Seventh Grade Eighth Grade
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) If Different Than Student #1
Address of Current School (If Different Than Student #1)

Street Address

Street Address Line 2

City State

Zip Code
Parent / Guardian Information

ONLY COMPLETE THIS SECTION IF THE INFORMATION IS DIFFERENT THAN INFORMATION PROVIDED FOR STUDENT #1
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 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 (If Different Than Student #1)

Both Parents Father Only Mother Only Joint Custody Other
Emergency Contacts

ONLY COMPLETE THIS SECTION IF THE INFORMATION IS DIFFERENT THAN INFORMATION PROVIDED FOR STUDENT #1
Emergency Contact 1
Name *

First Name Last Name
Phone Number *
Emergency Contact 2
Name

First Name Last Name
Phone Number *
Physician and Medical Information
Primary Care Physician's Name (If Different Than Student #1)

First Name Last Name
Primary Care Physician's Phone Number (If Different Than Student #1)
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
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Parent / Guardian #1 Email (Required for Confirmation Reply) *
example@example.com
IMPORTANT: You must click "FINISH" on the DocuSign site to complete the signature process. If "FINISH" isn't clicked, we will not receive your document.
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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:

Sign Electronically