Saint Patrick School

Student Name (Last, First, Middle)

Student Date of Birth (mm/dd/yyyy)

Date

Student Registering for Grade

Student Local Address (Number. City. State. Zip)

Student Ethnicity

Student Home Telephone Number

Format: (000) 000-0000.

Student lives with

Student County of Residence

Student School Corp. of Residence

Student's Siblings

Father/Guardian's Name (Last, First, Middle)

Cell Phone Number

Format: (000) 000-0000.

Work Phone Number (Extension)

Format: (000) 000-0000.

Employer/Company Name

Home Address If Not Same as Student (Number, City. State Zip)

Email Address

example@example.com

Mother/Guardian's Name (Last, First, Middle)

Cell Phone Number

Format: (000) 000-0000.

Work Phone Number (Extension)

Format: (000) 000-0000.

Employer/Company Name

Home Address If Not Same as Student (Number, City. State. Zip)

Email Address

example@example.com

Provide the name(s) of person(s). other than parents, allowed to pick up the student

Name (First. Middle. Last)

Relationship to Student

Home Telephone/Other Primary Number

Format: (000) 000-0000.

Name (First, Middle. Last)

Relationship to Student

Home Telephone/Other Primary Number

Format: (000) 000-0000.

Is there a visitation order or other court order banning any individual from removing the student during the school day or coming into contact with the student during the school day and do parents have shared parental responsibility?

*Please provide school with any court documentation

Please do not allow my student to be picked up by

Primary Doctor

Phone Number

Format: (000) 000-0000.

Dentist

Hospital Choice

Format: (000) 000-0000.

Insurance Carrier

Hospital Choice

(Parent/Guardian) gives St. Patrick Catholic School of the Terre Haute Deanery and its designated representative permission to transport and sign all forms related to the neccesary medical treatment for my student. I also permit any and all required medical treatment to be administered by qualified medical personnel. including calling 9-1-1.

Signature of Parent/Guardian

Date

Does this student have a current special education plan (ie, IEP, ISP, or CSEP)?

Does this student have any health concerns (diabetes, ADHD, etc.)?

Please list any/all medications student is taking

Any/all known allergies. including food and medications

Emergency Form