Mary of Nazareth Catholic School Campus
Student Information
Student Name
*
Grade
*
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, Please Explain:
Has your child ever received any of the following services? (If Yes, please check.)
*
Yes
No
Counseling
Emotional Support
Gifted Support
Title I Math
Title I Reading
Speech/Language
Project DART
Drug Rehabilitation
Alcohol Rehabilitation
Psychological Support
Alliance for Children
Has your child been diagnosed with any of the following? (If yes, please check diagnosis)
*
yes
no
ADD (Attention Deficit Disorder)
ADHD (Attention Deficit Hyperactive Disorder)
Aspergers Disorder
Autism
Dyslexia
ODD (Oppositional Defiant Disorder)
PDD (Pervasive Development Disorder)
Bipolar Disorder
Seizure Disorder
Does your child take medication associated with this disorder?
*
yes
no
If yes, please specify:
Has your child repeated a grade?
*
yes
no
If yes, which grade?
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 leave school?
*
yes
no
If yes, please explain:
Has your child been expelled from school?
*
yes
no
If yes, please explain:
Has your child had an IEP?
*
yes
no
Does your child have or need an IEP?
*
yes
no
If yes, please explain:
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Print Name
*
Emergency Information
Student 1 Last Name
*
Student 1 First Name
*
Student 1 Grade
*
Student 2 Last Name
Student 2 First Name
Student 2 Grade
Student 3 Last Name
Student 3 First Name
Student 3 Grade
Student 4 Last Name
Student 4 First Name
Student 4 Grade
Parent's/Guardian's Name
*
Home Address
*
Home Phone
*
Please enter a valid phone number.
Cell Phone Father
*
Please enter a valid phone number.
Cell Phone Mother
*
Please enter a valid phone number.
Business Phone Father
Please enter a valid phone number.
Business Phone Mother
Please enter a valid phone number.
Father Email
*
example@example.com
Mother Email
*
example@example.com
If my child should become ill during school hours and there is no one at home at the time, please contact the following:
Call 1st
*
Address (Full address please)
*
Phone Number
*
Please enter a valid phone number.
Call 2nd
*
Address (Full address please)
*
Phone Number
*
Please enter a valid phone number.
Call 3rd
Address (Full address please)
Phone Number
Please enter a valid phone number.
Physician
*
Address (Full address please)
*
Phone Number
*
Please enter a valid phone number.
Signature of Parent or Guardian
*
Family Update and Consent Form
Please review full text with PDF view at the foot of this form.
School Year
*
Father Name
*
Mother Name
*
CHILD(REN)'S NAME(S) AND GRADES
*
FAMILY NAME
*
Address (Full address please)
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Class List
*
Yes, I give my permission for my name, my child(ren)'s name, 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 further 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
*
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
*
I HAVE REVIEWED AND UNDERSTAND THE CONTENTS OF THE STUDENT/PARENT HANDBOOK OF PERCES,INC., MARY OF NAZARETH CATHOLIC SCHOOL CAMPUS.
Emergency/Evacuation Dismissal Parent Indicator and Agreement of Release and Indemnity
Please review full text in PDF preview below:
School District in which you reside:
*
In the event of an emergency dismissal, I/we would like my/our child/children
*
to be dismissed via school bus. (If a school bus is not provided by the school district in which you reside your child will remain at the 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.
Parents and guardians should designate themselves as designated custodians, friends, neighbors and other relatives may also be designated if they are able to transport your child/children.
Designated Custodian Name
*
Relationship
*
Phone Number
*
Please enter a valid phone number.
Designated Custodian Name
*
Relationship
*
Phone Number
*
Please enter a valid phone number.
Designated Custodian Name
Relationship
Phone Number
Please enter a valid phone number.
Parent/Guardian 1 Signature
*
Date
*
-
Month
-
Day
Year
Date
Name Printed
*
Parent/Guardian Signature 2
Date
-
Month
-
Day
Year
Date
Name Printed
Address (Full address please)
Phone 1
Please enter a valid phone number.
Phone 2
Please enter a valid phone number.
Individual Student Internet Use Contract
Please review full document by selecting Preview PDF below. Each child in the household who attends Mary of Nazareth Catholic School Campus, Grades K-8, must sign this agreement.
Student Signature 1
*
Grade
*
Student Signature 2
Grade
Student Signature 3
Grade
Student Signature 4
Grade
Parent/Guardian Signature 1
*
Name Printed
*
Parent/Guardian Signature 2
Name Printed
Date
*
-
Month
-
Day
Year
Date
Catholic School Parents Memorandum of Understanding
Please select Preview PDF below to review the full document. 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 Name Printed
*
Father Signature
*
Mother Name Printed
*
Mother Signature
*
Guardian Name Printed
Guardian Signature
Student's Name
*
Date
*
-
Month
-
Day
Year
Date
Thank you!
In order for a student to be accepted and registration finalized, all documentation must be submitted, FACTS tuition account must be established and the $100.00 NON-REFUNDABLE family registration fee paid. REGISTRATION WILL NOT BE ACCEPTED UNTIL FEE IS PAID. The registration fee will be applied to your tuition. CHECKS AND MONEY ORDERS SHOULD BE MADE PAYABLE TO "MARY OF NAZARETH CATHOLIC SCHOOL."DOCUMENTS REQUIRED:Student Original Birth Certificate (to be copied and returned)Student Immunization RecordStudent Baptismal Certificate (if applicable)Language SurveyMemorandum of UnderstandingPastor Verification Form (if applicable) Physical Examination Report (Grades K, 3 & 7 only)Dental Examination Report (Grades K, 3 & 7 only) Lead Testing Report (Grade K only)
Preview PDF
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