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St. Mary's School - Application Form
Application to be completed for student admission to St. Mary's School (Form needs to be completed for each child enrolling in St. Mary's School plus a $300 non-refundable application fee. Please contact school to arrange payment).
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* Indicates required question
Email
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Your email
Registered St. Mary's Parishioner
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Yes
No
Student Full Name (First, Middle, Last)
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Your answer
Student Date of Birth
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MM
/
DD
/
YYYY
Grade Entering
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Your answer
Gender
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Male
Female
Address
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Your answer
City
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Your answer
Zip Code
*
Your answer
Please check the category that pertains to your child:
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Native American: Having origins in any of the Indian people of North America, including Alaska-American Indians only.
Asian: Having origins in any of the peoples of the Far East, Southeast Asia, or the Pacific Islands (ex: China, Japan, Philippines, Korean, Vietnam)
Black Non-Hispanic: Having origins in any black racial group, no any Spanish speaking
Hispanic: Of any Spanish speaking culture or origin, regardless of race (ex: Mexico, Puerto Rico, Cuba, Central/South America)
White Non-Hispanic: Of European, Mediterranean, and Middle East Cultures
Bi-racial: Of two distinct areas (ex: Asian/White, Black/White, Asian/Black)
Required
School district you would attend if not going to St Mary's School
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Your answer
Name of Public School
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Your answer
My child will take medications during the day
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No
Yes - Medication Form MUST be on file in the office
Religious Information For Baptism, Reconciliation, First Communion, and Confirmation (please include Date, Church sacrament was received at, and City/State)
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Your answer
Child resides with
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Both Parents
Parent/Guardian A
Parent/Guardian B
Other
If above answer is "Other", please list below relationship to child
Your answer
Parent/Guardian "A" Name
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Your answer
Parent/Guardian "A" Relationship to child
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Your answer
Parent/Guardian "A" Address, City, State, Zip Code
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Your answer
Parent/Guardian "A" Occupation and Company Name
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Your answer
Parent/Guardian "A" Primary Phone Number
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Your answer
Parent/Guardian "A" Work Phone Number
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Your answer
Parent/Guardian "A" Primary E-Mail
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Your answer
Parent/Guardian "B" Name
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Your answer
Parent/Guardian "B" Relationship to child
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Your answer
Parent/Guardian "B" Address, City, State, Zip Code
*
Your answer
Parent/Guardian "B" Occupation and Company Name
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Your answer
Parent/Guardian "B" Primary Phone Number
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Your answer
Parent/Guardian "B" Work Phone Number
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Your answer
Parent/Guardian "B" Primary E-Mail
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Your answer
Academic Records for all new students of St Mary's School will be requested from prior school(s) and/or day care. Please list below the following: School(s) Attended, Date Enrolled, Date Withdrawn, and Reason For Leaving
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Your answer
Has your child ever been suspended, expelled, dismissed, or not allowed to re-enroll in a school
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No
Yes - If yes, please submit the name of the school and the reasons on a separate sheet of paper to St Mary's School office
Has your child ever been tested or evaluated for special accommodations, English as a Second Language, or medical conditions?
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No
Yes (ex: learning disabilities, IEP, 504 Plan, ADD/ADHD, emotional disabilities)
Has your child ever received intervention/support in the classroom for:
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Math
Reading
Writing
Behavior
None
If yes to any of the above, please list below any disability or medical condition that may affect your child's ability to fully participate in the academic program provided at St Mary's School. If you are requesting an adjustment or accommodation to the curriculum, please describe your request below. (
Information about disabilities is requested for the sole purpose of determining whether the school can provide the child with an appropriate education or reasonable accommodations and will not be considered in determining whether her/she is otherwise qualified for admission
).
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Your answer
Family Preferences - Please mark yes or no for the following questions.
Your answer
Student NAME may appear in school publications.
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Yes
No
Student PICTURE may appear in school publications.
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Yes
No
Student ARTWORK may appear in school publications.
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Yes
No
Student PICTURE/ARTWORK may appear in the school's social media (no name will appear).
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Yes
No
FAMILY ADDRESS may appear in school/class directory.
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Yes
No
FAMILY PHONE NUMBER may appear in school/class directory.
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Yes
No
FAMILY EMAIL may appear in school/class directory.
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Yes
No
(Please initial below) I understand it is my responsibility to read, abide by, and share with my child all policies in the St Mary's Student/Parent Handbook, which is online at
www.stmarysschool.net
, or I may request a copy from the school office.
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Your answer
(Please initial below) I understand that St Mary's School is in compliance with the mandates of the State of Illinois regarding asbestos management and abatement. A general management plan is on file with the Illinois Department of Public Health and Environmental Safety Division, and is available for public inspection. All necessary precautions have been accomplished and a designated inspector conducts on-going inspections.
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Your answer
(Please initial below) I have been notified per Illinois Law that information about sex offenders is available online. The website is in the Student/Parent Handbook.
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Your answer
(Please initial below) I have been notified that the Diocese of Peoria Safe Environment Curriculum is available.
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Your answer
How did you learn about St Mary's School?
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Your answer
What led you to consider St Mary's School for your child?
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Your answer
What are your goals for your child at St Mary's School?
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Your answer
A copy of your responses will be emailed to the address you provided.
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