CSDV018
Revised: SPS 4/3/2013
ST. PHILIP CATHOLIC SCHOOL
REGISTRATION FORM/NEW STUDENTS
STUDENT
BOY
LAST
D.O.B.
FIRST
GIRL
AGE
MIDDLE
SSN
U.S. CITIZEN
COUNTRY OF BIRTH
M /D/Y
HOME ADDRESS
CITY
STREET
LANGUAGES SPOKEN AT HOME
ZIP CODE
PHONE #
STUDENT’S RELIGION
CHURCH ATTENDING
FATHER’S NAME
SINGLE
DECEASED


SEPARATED
REMARRIED
OCCUPATION
RELIGION
FATHER’S EMAIL
PHONE #
FATHER’S EDUCATION: HIGH SCHOOL 
COLLEGE  BACHELOR’S DEGREE 
MOTHER’S NAME
SINGLE
DECEASED


SEPARATED
REMARRIED
RELIGION
MOTHER’S EMAIL
PHONE #
COLLEGE  BACHELOR’S DEGREE 
LEGAL GUARDIAN
MARRIED
DIVORCED
ADVANCED DEGREE 
OCCUPATION
MOTHER’S EDUCATION: HIGH SCHOOL 




OTHER 
MARRIED
DIVORCED
RELATIONSHIP TO STUDENT ______
PHONE #
STUDENT’S LEGAL ADDRESS
STREET
NUMBER OF CHILDREN IN FAMILY:
CITY
BOY(S)
GIRL(S)
ZIP CODE
SIBLING RANK
PUBLIC SCHOOL DISTRICT TO WHICH CHILD BELONGS
PUBLIC SCHOOL WHICH STUDENT WOULD ATTEND
ENTERING GRADE


ADVANCED DEGREE  OTHER 
ADDRESS
DISTRICT NUMBER


COUNTY
DATE OF ENTRY
TRANSFERRED FROM
BAPTISM
FIRST COMMUNION
CHURCH
DATE
CITY/STATE
Page 1 of 4
CONFIRMATION
CSDV018
Revised: SPS 4/3/2013
ADDENDUM TO THE REGISTRATION FORM
Describe any developmental delays, tutoring, or special education programs the child is receiving or
has received.
Describe any special needs of the child of which the school should be aware. (Educational, Health,
etc.)
Name(s) of children in the family and the grade and name of school each attends.
Name
Grade / School
Name
Grade / School
Page 2 of 4
CSDV018
Revised: SPS 4/3/2013
EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT 1
NAME: ______________________________
RELATIONSHIP: ______________________
PHONE #: ____________________________
EMERGENCY CONTACT 2
NAME: ______________________________
RELATIONSHIP: ______________________
PHONE #: _____________________________
DOCTOR’S NAME: ____________________________
DOCTOR’S PHONE NUMBER: __________________
HOSPITAL: ___________________________________
HOSPITAL PHONE NUMBER:____________________
MEDICAL INFORMATION
Section 25.01, Texas Family Code, enables the parent or guardian to authorize an educational institution (school official) to
consent to medical treatment of a minor. In case of emergency, this authorization could be used to obtain medical treatment when
unable to locate a parent or guardian quickly. As a parent or guardian, I authorize school personnel to consent to medical
treatment for my child in cases of emergency and to take my child to our doctor or to the emergency room at the hospital. I have
listed name of doctor and hospital to be used. If it is impossible to contact this physician, the school may make whatever
arrangements seem necessary.
Please indicate with an (X) which of the following conditions you child has had:
Asthma _____
Bronchitis ______
Chicken Pox ______
Convulsions _____
Diabetes _____
Ear Problems _____
Epilepsy ______
Heart Disease ______
Hepatitis ______
Kidney/Bladder Problems ______
Measles ______
Mumps ______
Pneumonia ______
Rheumatic Fever _____
Other ______________
Other ______________
Allergies (please list)
______________________________________________________________________________________
Date of Last DT Immunization? ____________________________________________________________
Is your child on any medication? _______ For what reason? ____________________________________
Parent / Guardian Signature
Please return completed form to:
St. Philip Catholic School
302 W. Church St.
El Campo TX 77437
You will receive a phone call to arrange an interview.
Page 3 of 4
CSDV018
Revised: SPS 4/3/2013
School:
Dear Parent:
Each year the Office of Catholic Schools as well as each individual school is required to provide information to the National
Catholic Education Association pertaining to the racial/ethnic demographics of our students. It is not the place of school officials
to designate individuals. It is appropriate that parents designate the one category among those listed below that best describes their
family background. Please assist us by providing the required information on this form.
Thank you for choosing to educate your child/children in a Catholic school in the Diocese of Victoria.
Sincerely,
John E. Quary
Superintendent of Schools
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Asian: identifies as having origins in Far East, Southeast Asia or Indian Sub-continent: (Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, Philippines, Thailand, Vietnam, etc.)
American Indian/Native American: identifies as one of the two classifications of native Americans
Black/African American: identifies as black whether from the U.S., Africa or other parts of the world
Hispanic: identifies as of Hispanic origin
Native Hawaiian/Other Pacific Islander: includes native Hawaiians living anywhere in the U.S.
(but not non-Hawaiian residents of Hawaii); also includes other Pacific Islands: Guam, Samoa, Fiji,
Micronesia, Polynesia
White: Caucasian from any part of the world (including Middle East) that does not identify as one of
the other groups
Multi-racial: person belongs to more than one racial group
Family Name:
Name(s) of children enrolled in this school:
Page 4 of 4