ST. ANN ACADEMY
New Student Application and Emergency Form
Student Entering Grade______
Please complete this form in its entirety. This information will be used by both the school and business office for information and
billing purposes. A non-refundable application fee of $300 MUST accompany this application. Only St. Ann Academy personnel will
use the emergency information provided. NON-PARENT emergency contacts who are available during the school day must be
provided in the event that parents are not reachable. PLEASE PRINT ALL INFORMATION!
Student Last Name
Student 1st Name & M.I.
Birth Date
M/F
City & County of Birth
U.S. Citizen ___ Yes ___No
Sibling Name
Sibling Birth Date
P
Sibling Name
Sibling Birth Date
Permission to Photograph? ___ Yes ___No
P
CIRCLE ONE: Race: American Indian/Native Alaskan Asian Black Native Hawaiian/Pacific Islander White
K
Two or More Races
3
CIRCLE ONE: Ethnicity: Hispanic
Non-Hispanic
Student is transferring from: Name of School _________________________ Address __________________________
s
Grade _________ Reason for Transfer: ________________________________________________________________
t
Please indicate uif the student is/has been enrolled in any of the following:
Learning Resource
Math Lab ___Yes ___No
Special Education ___Yes ___No
d Room ___Yes ___No
Special Tutoring
___Yes
___No
Reading
Lab
___Yes
___No
Counseling
___Yes ___No
e
Speech Therapyn
___Yes ___No
Other __________________________________________________
Has the studenttever repeated a grade? ____ Yes ____No If yes, which grade?
Has the student ever had a psychological and/or psycho-educational evaluation? ___Yes ___No ____________Date
Does the student
1 have an IEP (Individual Education Plan) or 504 Plan in place? ___Yes ___No
Does the student have any physical/psychological condition (asthma, hearing loss, ADHD, etc.) which would limit his/her
school activity or
n classroom functioning? ___Yes ____No Description ______________________________________
Has the studentahad any serious illness or hospitalization? ____Yes ____No ____Year Description_______________
MOTHER’S
INFORMATION
FATHER’S INFORMATION
m
Name
Name
e
Address
Address
_
City, State, Zip_
City, State, Zip
_
Home Phone
Home Phone
_
Cell Phone _
Cell Phone
_
Employer
Employer
_
Work Phone _
Work Phone
_
Occupation _
Occupation
Place of Birth _
Place of Birth
_
E-Mail Address
E-Mail Address
_
_
Include Info in School Directory? ____ Yes ____No
Include Info in School Directory? ____ Yes ____No
_
Religion
Religion
_
_
Parish
Parish
_
_
_
PLEASE INDICATE BELOW IF YOU REQUIRE BEFORE SCHOOL PROGRAM AND/OR AFTERSCHOOL PROGRAM
_
_
OPTION 1
_____$100 per month
for 1 child ($80 for 2nd child and $0 for 3+ children added to your monthly Tuition Bill (this covers both programs
_
up until 5:30pm)_
OPTION 2
_
_____$8.00 an hour drop-in rate per child
_
_
_
NON-PARENT EMERGENCY CONTACTS
_NAME
RELATIONSHIP
DAYTIME PHONE
X
A
Children live with
_____Mother
_____Father ______Grandparent _____Guardian
Who has custody?
_____Mother
_____Father ______Grandparent _____Guardian
Are Visitation Rights permitted to non-custodial parent?
_____ Yes
____ No
Family Doctor
__________________________________________ Phone____________________________
Family Dentist
________________________________________
Hospital Preference:
_______ Bridgeport
Phone____________________________
_______ St. Vincent’s
_______ Closest
Please indicate Yes or No to each category. Describe if necessary.
MEDICATIONS
ALLERGIES
ASTHMA
DIABETES
HEART
PROBLEMS
EPILEPSY
RECURRING
ILLNESS
OTHER
DISMISSAL ARRANGEMENTS
These instructions will be followed UNLESS the school office receives WRITTEN NOTICE of any exceptions. Phone calls will be
accepted only in an emergency. Please avoid frequent exceptions, as this causes confusion and potential safety issues.
REGULAR DISMISSAL (Includes Scheduled Early Dismissals). PLEASE CHOOSE ONLY ONE!
______ ASP (After School Program)Estimated Pick Up time __________________
Authorized Person #1 (Non Parent)_____________________________________________
______ Bus
Morning Only ______
Afternoon Only ______
Both Morning and Afternoon ________
______ Escorted Dismissal (Authorized Person must meet your child(ren) in driveway at front door))
Authorized Person #1 (Non Parent)_____________________________________________
_____
Unescorted Dismissal (Your child(ren) is/are allowed to walk off campus (including to your car) alone.
UNSCHEDULED EARLY DISMISSAL. PLEASE CHOOSE ONLY ONE!
NOTE: THERE IS NO ASP ON THESE DAYS!
______ Bus
_____ Escorted Dismissal
______ Unescorted Dismissal
How did you hear about us (check all that apply)?
Billboard- where?___________
Family of Current Student - name ___________________
Alumni – name _____________
Realtor – name _______________
St. Ann School Website
Parishioner – name _______________
Other Website ____________
Catholic Schools Office
Other__________
I certify that all of the above information is accurate, and that I and my children have read and agree to abide by the policies and
procedures as outlined in the St. Ann School Family Handbook.
PARENT/GUARDIAN SIGNATURE________________________________________________DATE__________________________
ALUMNI INFORMATION
Is anyone in your family an alumnus of St. Ann School? ______Yes
If yes, please provide the following:
____No
(Pre-Marital) Name___________________________________________ Graduation Yr. ______________
For Office Use Only:
Fee Paid_________
Check # _________________