Student_Info

Mandatory Student Form
Student's Name 1*

First NameLast Name
Grade*
Student's Name 2

First NameLast Name
Grade
Student's Name 3

First NameLast Name
Grade
Student's Name 4

First NameLast Name
Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child/Children Live with:

Both ParentsMother as Custodial ParentFather as Custodial ParentFamily Member (with Legal Custody)Other*
*If Other, Please Explain
Check if applicable:

Is there a court order (or pending order) affecting the custody and/or residency of the child?If there is a non-residential parent, do they have visitation rights?Is there a court decision that states that the non-residential parent should NOT receive school information or attend school activities?Is the non-residential parent responsible for paying tuition and fees?
Mother/Guardian's Name

First NameLast Name
Mother/Guardian's Email
example@example.com
Mother/Guardian's Cell Number
Please enter a valid phone number.
Mother/Guardian's Work Number
Please enter a valid phone number.
Father/Guardian's Name

First NameLast Name
Father/Guardian's Email
example@example.com
Father/Guardian's Cell Number
Please enter a valid phone number.
Father/Guardian's Work Number
Please enter a valid phone number.

Emergency Contacts

In case of emergency and the parent/guardian is not available, contact:
Contact #1*

First NameLast Name
Relationship to Student*
Phone Number*
Please enter a valid phone number.
Authorized to Pick Up*

YesNo
Contact #2*

First NameLast Name
Relationship to Student*
Phone Number*
Please enter a valid phone number.
Authorized to Pick Up*

YesNo
Contact #3

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Authorized to Pick Up

YesNo
Contact #4

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Authorized to Pick Up

YesNo

Part 1 or Part 2 must be completed
Part 1

In the event reasonable attempts to contact may have been unsuccessful, I hereby give consent for the administration of any treatment deemed necessary by the physician or dentist, or in the event the designated practitioner is not available, by another licensed physician or dentist and the transfer of the child to the preferred hospital or most easily accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed. Facts concerning the child's medical history including allergies, medication being taken and any physical impairment to which a physician should be alerted.
Preferred Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Preferred Dentist's Name
Dentist's Phone Number
Please enter a valid phone number.
Preferred Hospital
Part 2

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action or to:
Briefly state acceptable actions for your child

Acknowledgement of Family Handbook
Access the Handbook: maryqueenofpeaceschool.com/resources

Acknowledgement and receipt and review of the Mary Queen of Peace School Polices and Procedures.

I understand that I will be responsible for complying with the policy. I may request a hard copy if needed.

I further understand that any questions regarding this Policy should be referred to the Principal.

I further understand that Mary Queen of Peace reserves the right to change, modify, and/or revise any part of this policy at any time.

I have discussed it with my child/children.

If this form is not completed, it will be assumed that the handbook was read adn that you have agreed to all of the information.
We have read and agree to abide by this Mary Queen of Peace Family Handbook 2024-2025.*

I read and agree.
Parent/Guardian's Signature*

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Mandatory Student Form