SACRED HEART SCHOOL 701 Franklin Street, West Reading, PA 19611 610-373-3316

ADMISSIONS APPLICATION
Date of Application *

- Month - Day Year
Date
Catholic *
Non-Catholic/Religion
PARISH IN WHICH YOU ARE REGISTERED
Student Information
Entering Grade *
Sex *
Date of Birth (mm-dd-yyyy) *

- Month - Day Year
Date
Place of Birth (country/city/state) *
Last Name *
First Name *
Middle Name
Street Address *
City *
State *
Zip Code *
Home phone number *
Ethnic Background
Transportation *
Public School District of Residence *
Notes:
Parent Information - Father
Name - First/Last *
Street Address *
City, State, Zip *
Religion
Employer *
Occupation
Work Phone Number
Cell Phone Number *
Email address *
Country of Birth
Parent Information - Mother
Name - First/Last *
Street Address *
City, State, Zip *
Religion
Employer *
Occupation
Work Phone Number
Cell Phone Number *
Email address *
Country of Birth
Mother"s Maiden Name
Parent"s Marital Status *
Student resides with *
Custody
If other, explain completely giving names and relationships
Full name of Stepparent
Full name of Guardian (see Addendum #1)
Addendum #1 In an effort to acknowledge the rights of parents regarding access of information, we ask that you submit any court documentation that substantiates your legal status as it relates to the child being enrolled in Sacred Heart School. If this addendum does not apply, choose "not applicable" **Documentation must be submitted to the school as soon as possible, so your application may be processed.** *

SACRAMENTAL INFORMATION
Baptism:
Date

- Month - Day Year
Date
Church
City/State/Zip
Reconciliation:
Date

- Month - Day Year
Date
Church
City/State/Zip
First Communion:
Date

- Month - Day Year
Date
Church
City/State/Zip
Confirmation:
Date

- Month - Day Year
Date
Church
City/State/Zip
SCHOOL INFORMATION
School Previously Attended: *
Address
MEDICAL INFORMATION
Special Medical Information
Family Doctor *
Family Doctor Phone number *
Please list the names, ages, and schools of ALL children in the family
Name - First/Last
Age
School
Name - First/Last
Age
School
Name - First/Last
Age
School
Name - First/Last
Age
School
Name - First/Last
Age
School
If more than 5 children, list here
Is another language spoken at home? *

yes no
If yes, what language

Diocese of Allentown ENGLISH Home Language Survey* The Office of Civil Rights (OCR) requires that the school districts/charter schools/full day AVTS identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method of identification.
School District *
Name of child *
Date *

- Month - Day Year
Date
Address *
Grade *
School *
Birthplace *
1. What is/was the student"s first language? *
2.Does the student speak a language(s) other than English? *

yes no
If yes, specify the language(s)
3. What language(s) is/are spoken in your home? *
4. Has the student attended any United States school in any 3 years during his/her lifetime? *

yes no
If yes, complete the following:
Name of School
State
Dates Attended start

- Month - Day Year
Date
Dates Attended end

- Month - Day Year
Date
Name of School
State
Dates Attended start

- Month - Day Year
Date
Dates Attended end

- Month - Day Year
Date
Name of School
State
Dates Attended start

- Month - Day Year
Date
Dates Attended end

- Month - Day Year
Date
Person completing this form (if other than parent/guardian)
By checking this box and printing my name below, I am electronically signing this survey *

I have agreed to submit survey electronically
Parent/Guardian signature (print full name) *
*The school district/charter school/full day AVTS has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the school district/charter school/full day AVTS has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district/charter school/full day AVTS may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the school district/charter school/full day AVTS in the future.
For Office Use Only Exemption from English Language Proficiency Testing (attach required documentation) (Must meet two out of the three criteria - please indicate with a check the two appropriate criteria met _____ Final grades of B or better in core subject areas (Mathematics, Language Arts, Science, Social Studies) _____ Scores equivalent to Basic performance on district wide assessment (e.g. 4 Sight) _____ Scores of Basic in Reading, Writing and Math on the PSSA

SIGN AND PRINT
By checking this box and printing my name below, I am electronically signing this Admissions Application *

I have agreed to submit application electronically
Signature (print full name) *
Paypal payment - 1 Child $51.50 Family - $78.00 (service fee added)

USD Registration
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