New Student Registration

New Student Registration

Mary of Nazareth Catholic School
SCHOOL YEAR
ENTERING GRADE
PS 3 - 3 Day or 5 Day (Please Choose)

3 Day 5 Day
TRANSPORTATION: Child will be a

Car Rider Walker Bus Rider
Name

First Name Middle Name Student's Last Name
Address
City
State
Zip
Male/Female (as identified at birth)
Home Phone
Cell Phone
Date of Birth

Month Day Year
Date
Age as of August 31
Birth Place
City
County
Country (if outside USA)
US Citizen

Yes No
Ethnicity

African-American Hispanic Asian Native American Caucasian Multi-Racial Pacific Island Other
Language spoken at home (90% of the time)
Does your child have special medical needs?

Allergies, Yes Allergies, No Diabetes, Yes Diabetes, No Hearing, Yes Hearing, No Vision, Yes Vision, No Other
If yes to Allergies, what is the Allergy:
Public School District of Residence (Taxes paid to):
Public school building this student would attend, if not enrolled in Mary of Nazareth Catholic School:
Current school (if any)
Address of current school
Religion
If Catholic, Parish and Diocese
SACRAMENTAL INFORMATION OF APPLICANT:
Baptism: Date, Church, City and State
Reconciliation: Date, Church, City and State
Holy Eucharist: Date, Church, City and State
Confirmation: Date, Church, City and State
FAMILY DATA
Mother First and Last Name
Father First and Last Name
Mother's Address
Father's Address
Mother's Home Phone
Father's Home Phone
Mother's Cell Phone
Father's Cell Phone
Mother's Emergency Phone
Father's Emergency Phone
Mother's Email
example@example.com
Father's Email
example@example.com
Mother's Occupation
Father's Occupation
Mother's Employer
Father's Employer
Mother's Business Phone
Father's Business Phone
Mother's Religion
Father's Religion
Mother's Parish where registered
Father's Parish where registered
Mother, Catholic School Alumni

Yes No
Father, Catholic School Alumni

Yes No
Student resides with

Both parents Mother only Father only Joint Custody Other
Parents/Guardians Marital Status

Married Separated Divorced Widowed Single Parent
Please list any talents or interests you will be willing to share with the school
Student's legal guardian (if other than parent)
Relationship to the student
Address
Home Phone
Cell Phone
Emergency Phone
E mail
example@example.com
Occupation
Employer
Business Phone
Religion
Parish where registered
Mail will be sent to the student's address.

If mail is to be sent to a second address, please complete:
NAME
RELATIONSHIP
ADDRESS
BROTHERS/SISTERS (In order of birth):
Name, Gender, Date of Birth
Name, Gender, Date of Birth
Name, Gender, Date of Birth
Name, Gender, Date of Birth
In order to provide the best education for your child, please complete the following:
Has your child ever had a psychological evaluation?

Yes No
Has your child ever been diagnosed with any of the following?

Yes (Diagnosis Listed Below, Please check all applicable) No
LD (Learning Disability) ADD (Attention Deficit Disorder) ADHD (Attention Deficit Hyperactive Disorder) ASD Autism Aspergers Dyslexia ODD (Oppositional Defiant Disorder) PDD (Pervasive Development Disorder) Other
Has your child received any of the following services:

Counseling Emotional Support Gifted Support Title I Math Title I Reading Speech/Language Project DART Drug Rehabilitation Alcohol Rehabilitation Psychological Support Learning Support Other
Does your child take medication associated with this diagnosis?

yes no
If yes, please specify
Has your child had an IEP?

yes no
If yes, what is the disability?
Please submit a copy of the IEP and evaluation.
Has your child had a 504 plan?

yes no
If yes, what is the disability? (Please submit a copy of the 504.
6.Been diagnosed with a medical condition that the school should be aware of?

yes no
If yes, please explain
Has your child repeated a grade?

yes no
If yes, which grade?
Why?
Has your child received a suspension from school?

yes no
If yes, please explain
Has your child received a suspension for weapons, drugs, alcohol, tobacco or internet violations?

yes no
If yes, please explain
Has your child been asked to transfer?

yes no
If yes, please explain
Has your child been expelled from school?

yes no
If yes, please explain
PLEASE RETURN THIS APPLICATION PACKET WITH A NON-REFUNDABLE FEE OF $20.00.

CHECKS AND MONEY ORDERS SHOULD BE MADE PAYABLE TO MARY OF NAZARETH CATHOLIC SCHOOL.

IN ORDER FOR A STUDENT TO BE ACCEPTED AND REGISTRATION FINALIZED, ALL DOCUMENTATION AS NOTED ONTHEBOTTOM OF THE FIRST PAGE MUST BE SUBMITTED.

NEW STUDENTS ARE ACCEPTED ON A PROBATIONARY BASIS. NEW STUDENTS AND THEIR FAMILIES SHOULD BE COGNIZANT OF, AND WILLING TO COMPLY WITH, ALL SCHOOL EXPECTATIONS. IF PROBLEMS ARISE DURING THE PROBATIONARY PERIOD WHICH HAVE NOT BEEN RESOLVED, THE STUDENT WILL BE REQUIRED TO TRANSFER.
PARENT/GUARDIAN SIGNATURE

Clear
DATE

Month Day Year
Date
Emergency Information
Child 1: Last Name
Child 1: First Name
Child 1: Grade
Child 2: Last Name
Child 2: First Name
Child 2: Grade
Child 3: Last Name
Child 3: First Name
Child 3: Grade
Child 4: Last Name
Child 4: First Name
Child 4: Grade
Parent's/Guardian's Name
Home Address
Home Phone Number
Please enter a valid phone number.
Father's Cell Phone Number
Please enter a valid phone number.
Mother's Cell Phone Number
Please enter a valid phone number.
Father's Business Phone Number
Please enter a valid phone number.
Mother's Business Phone Number
Please enter a valid phone number.
Father Email
example@example.com
Mother Email
example@example.com
First Emergency Contact
Address
Phone Number
Please enter a valid phone number.
Second Emergency Contact
Address
Phone Number
Please enter a valid phone number.
Third Emergency Contact
Address
Phone Number
Please enter a valid phone number.
Physician
Address
Phone Number
Please enter a valid phone number.
Signature

Clear
Family Update and Consent Form

2020-2021
Father's Name
Mother's Name
CHILD(REN)'S NAME(S)
Family Name
Address
Phone Number
Please enter a valid phone number.
A class list will be given to the homeroom parents including your child's name, family name, phone # and email.

Yes, I give permission for my name, my children's names, phone # and email to be given to the homeroom parents. No, I do not want my information given to the homeroom parents.
Photo Release:

□ I HEREBY CONSENT TO HAVING MY CHILD(REN)’S PICTURE TAKEN WHILE AT PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS OR ANY OF ITS SPONSORED FUNCTIONS. I FURTHUR CONSENT TO THE USE OF THE SAME FOR PURPOSES SUCH AS BROCHURES, ADVERTISING, EDITORIAL PUBLICATIONS, SPORTS PUBLICATIONS, SCHOOL SCRAP BOOKS, ETC. I AGREE THAT SUCH PICTURES CONNECTED THEREWITH SHALL REMAIN THE PROPERTY OF PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS. I DO NOT CONSENT TO THE ABOVE PHOTO RELEASE.
Loan of Textbooks: STATE LEGISLATION AUTHORIZES THE LOAN OF TEXTBOOKS AND INSTRUCTIONAL MATERIALS BY THE SECRETARY OF EDUCATION TO CHILDREN ENROLLED IN KINDERGARTEN THROUGH GRADE 12 IN NONPUBLIC SCHOOLS. OUR SCHOOL IS NOW IN THE PROCESS OF REQUESTING THE SPECIFIC TEXTBOOKS AND MATERIALS TO BE LOANED TO YOUR CHILD(REN). IT IS REQUIRED, HOWEVER, THAT A PARENT OF EACH CHILD ATTENDING THE NONPUBLIC SCHOOL INDIVIDUALLY REQUESTS A LOAN OF TEXTBOOKS AND INSTRUCTIONAL MATERIALS.

I, HEREBY, REQUEST THE LOAN OF TEXTBOOKS AND INSTRUCTIONAL MATERIALS IN ACCORDANCE WITH THE PENNSYLVANIA SCHOOL CODE OF 1949 FOR MY CHILD(REN) ATTENDING PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS.
Handbook: IT IS IMPORTANT THAT PARENTS/GUARDIANS, STUDENTS, AND STAFF KNOW THE POLICIES AND PROCEDURES OF PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS. TO ENSURE THAT THE PROCESS OF COMMUNICATION IS COMPLETE, PLEASE READ THE STUDENT/PARENT HANDBOOK WITH YOUR CHILDREN.

I HAVE REVIEWED AND UNDERSTAND THE CONTENTS OF THE STUDENT/PARENT HANDBOOK OF PERCES,INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS.
Emergency Evacuation/Dismissal

I/WE, AUTHORIZE PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS AND THE MCKEESPORT AREA SCHOOL DISTRICT TO RELEASE MY CHILD/CHILDREN TO THE PERSONS DESIGNATED IN CONSONANCE WITH PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS AND THE MCKEESPORT AREA SCHOOL DISTRICT EMERGENCY OPERATIONS PLAN. PARENTS AND GUARDIANS SHOULD DESIGNATE THEMSELVES AS DESIGNATED CUSTODIANS. FRIENDS, NEIGHBORS AND OTHER RELATIVES MAY BE SO DESIGNATED IF THEY ARE ABLE TO TRANSPORT YOUR CHILD/CHILDREN.
School District in which you reside:
IN THE EVENT OF AN EMERGENCY DISMISSAL, I/WE WOULD LIKE MY/OUR CHILD/CHILDREN (please choose one)

TO BE DISMISSED VIA SCHOOL BUS. (IF A SCHOOL BUS IS NOT PROVIDED BY THE SCHOOL DISTRICT IN WHICH YOU RESIDE YOUR CHILD/CHILDREN WILL REMAIN AT SCHOOL UNTIL PARENT/GUARDIAN OR AUTHORIZED PERSON COMES IMMEDIATELY TO PICK THEM UP.) TO REMAIN AT SCHOOL UNTIL PARENT/GUARDIAN OR AUTHORIZED PERSON COMES IMMEDIATELY TO PICK UP MY/OUR CHILD/CHILDREN.
Emergency Custodian 1 (Parents/Guardians should designate themselves as designated custodians. Friends, neighbors and other relatives may be so designated if they are able to transport your children.
Custodian 1 Relationship
Phone Number
Please enter a valid phone number.
Custodian 2 Name
Relationship
Phone Number
Please enter a valid phone number.
Custodian 3 Name
Relationship
Phone Number
Please enter a valid phone number.
Guardian 1 Signature

Clear
Date

Month Day Year
Date
Name

First Name Last Name
Guardian 2 Signature

Clear
Date

Month Day Year
Date
Name

First Name Last Name
Address
Phone Number 1
Please enter a valid phone number.
Phone Number 2
Please enter a valid phone number.
Mary of Nazareth Catholic School

Addendum for Transfer Students
Parent(s) Name
I/We understand that my/our child(ren) will be attending a Catholic school and as such I/we understand that the Catholic school does not follow any guidelines, rules, laws, etc. that the public school is bound to follow. The following is not an exhaustive list but highlights some of the more common examples such as curriculum, promotion/retention IEP's, distribution of medications, 504 Plans, use of technology devices (including cell phones), et al.

I/We understand that all transfer students enroll with a maximum 90 day probation period and that if there are any extenuating circumstances that occur during those 90 days, the child will be withdrawn from the school program. Records will be forwarded to the receiving school.
Initial
I/We further understand that Mary of Nazareth Catholic School does not have a nurse on staff; a nurse is provided to the Catholic school on a part time basis and may only be in the building one half day per week and that the days vary.

I/We understand that the Diocese of Pittsburgh has a policy in place regarding the distribution of medication. All students must be able to self- medicate and medication must be brought to school in the original container with directions from the treating physician. It is the parent responsibility to keep all medical information updated.
Initial
Parent Signature

Clear
Date

Month Day Year
Date
Parent Signature

Clear
Date

Month Day Year
Date
Home Language Survey

The Civil Rights Law of 1964, Title VI, requires that school districts/charter schools identify Limited English Proficient (LEP) students. Pennsylvania has selected the Home Language Survey as the method for the identification.
School District
Date

Month Day Year
Date
Student's Name
Grade
What is the student's first language?
Does the student speak a language other than English?
If yes, specify language:
What languages are spoken in your home?
Person completing this form (if other than parent/guardian):
Signature

Clear
Catholic School Parents Memorandum of Understanding

As a parent/guardian of a student in a Catholic school, I understand, affirm, and support the following: 1. The primary purpose of a Catholic school education is to form students in the values of Jesus Christ and the teaching of the Catholic Church.2. Catholic schools are distinctive religious education institutions operated as programs of the Catholic Church; they are not private schools but are administered and supported by the sponsoring parish(es), the diocese, or religious community.3. Attending a Catholic school is a privilege, not a right.4. While academic excellence and involvement in extracurricular activity (i.e., sports, clubs, etc.) are important, fidelity to the Catholic identity of the school is the fundamental priority.5. The school and its administration have the responsibility to ensure that Catholic values and moral integrity permeate every facet of the school's life and activity.6. In all questions involving faith, morals, faith teaching, and Church law, the final determination rests with the diocesan bishop. As a parent/guardian desiring to enroll my child in a Catholic school, I accept this memorandum of understanding. I pledge support for the Catholic identity and mission of this school and by enrolling my child I commit myself to uphold all the principles and policies that govern a Catholic school.
Father's Name
Father's Signature

Clear
Mother's Name
Mother's Signature

Clear
Guardian Name
Guardian Signature

Clear
Student's Name
Date

Month Day Year
Date
Request for Academic, School and Health Records
School District
Name of School
Address of School
City, State, Zip of School
Student Full Name
Student Entering Grade
Signature

Clear
Date

Month Day Year
Date
Guideline for Internet Use Policy Implementation and Practice

THIS GUIDELINE IS ESTABLISHED TO ENSURE UNDERSTANDING AND APPLICATION OF PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS INTERNET USE POLICY. MARY OF NAZARETH CATHOLIC SCHOOL RESERVES THE RIGHT TO AMEND THESE GUIDELINES AT ANY TIME. IT IS UNDERSTOOD THAT THE ADMINISTRATION OF PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS WILL INFORM PARENTS/GUARDIANS OF ANY CHANGES MADE IN THESE GUIDELINES. STUDENTS’ PARENTS AND/OR GUARDIANS ARE REQUIRED TO REVIEW THESE GUIDELINES WITH THEIR CHILD(REN). THIS GUIDLINE INCLUDES, BUT IS NOT LIMITED TO THE FOLLOWING AREAS:  INFORMATION AND NEWS FROM A WIDE VARIETY OF SOURCES AND RESEARCH INSTITUTIONS  PUBLIC DOMAIN AND SHAREWARE SOFTWARE OF ALL TYPES  DISCUSSION GROUPS  ACCESS TO ANY EDUCATIONAL INSTITUTIONS AND LIBRARIES ETIQUETTE:  BE POLITE WHEN SENDING WRITTEN MESSAGES TO OTHERS  APPROPRIATE LANGUAGE IS EXPECTED IN ALL MESSAGES  ANYTHING PERTAINING TO ILLEGAL ACTIVITY IS EXPRESSLY FORBIDDEN  DO NOT REVEAL ACCESS INFORMATION, PERSONAL OR OTHERWISE  DO NOT DISRUPT OTHERS’ USE OF THE INTERNET ACCESS  ALL USERS SHOULD REMEMBER THAT DELETED MATERIALS COULD BE RETRIEVED THE FOLLOWING ACTIONS, WHICH ARE NOT INCLUSIVE, ARE CONSIDERED UNACCEPTABLE ACTIONS BY THE ADMINISTRATION OF PERCES, INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS AND MAY RESULT IN SERIOUS CONSEQUENCES:  PLACING UNLAWFUL INFORMATION ON THE INTERNET  USING THE INTERNET FOR NON-SCHOOL RELATED ACTIVITIES  SENDING MESSAGES THAT ARE LIKELY TO RESULT IN LOSS OF THE RECIPIENTS WORK OR SYSTEMS  USING THE INTERNET FOR COMMERCIAL PURPOSES  USING THE INTERNET FOR POLITICAL LOBBYING THAT DOES NOT SUPPORT THE EXPRESSED PHILOSOPHY AND TENETS OF THE CATHOLIC CHUCH  SENDING OR RECEIVING COPYRIGHTED MATERIAL WITHOUT PERMISSION  PLAGIARISM  USING INTERNET ACCESS TO SEND OR RETRIEVE PORNOGRAPHIC MATERIAL,INAPPROPRIATE FILE TEXT, FILES DANGEROUS TO THE INTEGRITY OF THE SYSTEM, VIOLENT OR THREATENING MATERIAL OR MESSAGES  CIRCUMVENTING SECURITY MESURES ON SCHOOL OR REMOTE COMPUTERS OR NETWORKS  VANDALISM  FALSIFYING ONE’S IDENTITY
Student 1 Signature

Clear
Student 1 Grade
Student 2 Signature

Clear
Student 2 Grade
Student 3 Signature

Clear
Student 3 Grade
Student 4 Signature

Clear
Student 4 Grade
Parent/Guardian 1 Signature

Clear
Parent/Guardian 1 Name
Parent/Guardian 2 Signature

Clear
Parent/Guardian 2 Name
Date

Month Day Year
Date
Thank you!

Please submit the follow documents to chriscandiello@yahoo.com. 1) Student Original Birth Certificate (to be copied and returned). 2) Student Immunization Record. 3) Student Baptismal Certificate (if applicable). 4) $20.00 Registration Fee. And the following forms which can be found on our school website: 1) Physical Examination Report (Grades K & 6 only). 2) Dental Examination Report (Grades K, 3 & 7 only). 3) Lead Testing Report (Grade K only).
Should be Empty:

New Student Registration

SACRAMENTAL INFORMATION OF APPLICANT:

Emergency Information

Family Update and Consent Form

Emergency Evacuation/Dismissal

Home Language Survey

Catholic School Parents Memorandum of Understanding

Request for Academic, School and Health Records

Thank you!