2021-22 St. Mary Registration Application

Only new students applying for admission to St. Mary for the 2021-22 school year should complete the form below. Parents of currently enrolled students are emailed a form to verify they will be returning.

Parents/Guardians of new students will be contacted about additional paper documents required to complete their registration.

Father/Guardian Information

Please indicate relationship to student(s)

Father

Guardian

Clear selection

First Name

Last Name

Street Address

City, State, and Zip Code

Email

Home Phone

Work Phone

Cell Phone

Employer

Occupation

Is father/guardian a St. Mary alumni?

Yes

No

Clear selection

If an alumni, what year did you graduate?

Mother/Guardian Information

Please Indicate relationship to student(s):

Mother

Guardian

Clear selection

First Name

Last Name

Street Address

City, State, and Zip Code

Email

Home Phone

Work Phone

Cell Phone

Occupation

Employer

Is mother/guardian a St. Mary alumni?

Yes

No

Clear selection

If an alumni, what year did you graduate?

School Registration

Please complete information on the new student(s) in your family who will be attending St. Mary School System.

If enrolling more than 3 children, please complete a second on-line registration form.

1. Student's First Name

Middle Name

Last Name

Name student prefers to be called:

Gender

Female

Male

Clear selection

Birthdate

MM

/

DD

/

YYYY

Student lives with:

Both parents

Mother

Father

Other:

Clear selection

Grade Entering 2021-22 School Year (Preschool-12th grade)

Public School District in which you reside *

School Student Currently Attends (include city and state)

My child

receives speech services.

has been identified with a disability which impacts his/her learning.

has an Individualized Learning Plan (IEP) or a 504 Plan.

receives Title 1 services.

none of the above.

Ethnicity

Hispanic/Latino

Non-Hispanic/Latino

Clear selection

Race: (Please mark all that apply)

Asian

Black/African American

Hispanic/Latino

Native American/Alaska Native

Pacific Islander

White

Two or more races

Other:

2. Student's First Name

Middle Name

Last Name

Name student prefers to be called:

Gender

Female

Male

Clear selection

Birthdate

MM

/

DD

/

YYYY

Student lives with:

Both parents

Mother

Father

Other:

Clear selection

Grade Entering 2021-22 School Year (Preschool-12th grade)

Public School District in which you reside

School Student Currently Attends (include city and state)

My child

receives speech services.

has been identified with a disability which impacts his/her learning.

has an Individualized Learning Plan (IEP) or a 504 Plan.

receives Title 1 services

none of the above.

Ethnicity

Hispanic/Latino

Non-Hispanic/Latino

Clear selection

Race: (Please mark all that apply)

Asian

Black/African American

Hispanic/Latino

Native American/Alaska Native

Pacific Islander

White

Two or more races

Other:

3. Student's First Name

Middle Name

Last Name

Name student prefers to be called:

Gender

Female

Male

Clear selection

Birthdate

MM

/

DD

/

YYYY

Student lives with:

Both parents

Mother

Father

Other:

Clear selection

Grade Entering 2021-22 School Year (Preschool-12th grade)

School Student Currently Attends (include city and state)

Public School District in which you reside

My child

receives speech services.

has been identified with a disability which impact his/her learning.

has an Individualized Learning Plan (IEP) or a 504 Plan.

receives Title 1 services.

none of the above.

Ethnicity

Hispanic/Latino

Non-Hispanic/Latino

Clear selection

Race: (Please mark all that apply)

Asian

Black/African American

Hispanic/Latino

Native American/Alaska Native

Pacific Islander

White

Two or more races

Other:

HOUSEHOLD INFORMATION

Religious Affiliation

If Catholic affiliation, please select one of the options below for which parish you are a member:

St. Thomas More

St. Francis de Sales

St. John the Evangelist

Rosary Chapel

St. Mary's Catholic Church

St. Joseph (Mayfield)

St. Jerome

Other Catholic parish (please complete the next question)

Not currently a registered member of a parish

Clear selection

If attending a Catholic Parish not listed above, please specify:

DIVORCED OR SEPARATED PARENTS

St. Mary MUST have a copy of the divorce decree with the most current custody arrangements on file in the school office.

If Divorced or Separated, who is the custodial parent?

May child(ren) be released to non-custodial parent?

Yes

No

Clear selection

EMERGENCY INFORMATION

In case of an emergency *

I give the school staff permission to release my child(ren) to the adults listed on this form or any adult St. Mary School System would deem responsible to care for my child(ren).

I give the school staff permission to release my child(ren) ONLY to the adults listed on this form.

Below list three (3) adults and their daytime phone numbers, to whom the school is authorized to release your child(ren)

1. Adult Name (First and Last) *

Phone Number *

Relationship to Child(ren) *

2. Adult Name (First and Last) *

Phone Number *

Relationship to Child(ren) *

3. Adult Name (First and Last)

Phone Number

Relationship to Child(ren)

EMERGENCY MEDICAL INFORMATION

Physician Name *

Physician Phone Number *

Dentist Name *

Dentist Phone Number *

Hospital of Choice *

Please list any pertinent medication/treatments/allergies for each of your child(ren) below.

Please mark your answer: *

I do want to develop a medical plan with the school nurse for my child's allergy, medical condition, etc.

I do NOT want to develop a medical plan with the school nurse for my child's allergy, medical condition, etc.

My child does not have any medical conditions that would require a medical plan.

I consent for St. Mary School System to use my child(ren)'s name(s) and photo(s) in news publications, on social media, or on marketing materials. *

Yes, I consent.

No, I do not consent.

Please read the policies below and mark the boxes to indicate that you have read and understand the policies: *

I understand the school will seek emergency medical treatment for my children in the event I cannot be contacted. I understand I am financially responsible for any expenses for medical care or transportation incurred on my child(ren)'s behalf. In the event of a serious injury, I understand that 911 will be called.

I understand that all new students will be given a trial period of not less than one semester in which to prove himself/herself both socially and academically. If during this trial period there are any problems, a student may be asked to withdraw his/her attendance at St. Mary.

Tuition Obligation (for K-12th grade): I understand St. Mary School System must make commitments to hire personnel and must incur expenditures for the academic year based on registration for the upcoming school year. I agree to pay tuition for the full semester each child attends, regardless of the withdrawal date. In the event that a student's account is not current, I acknowledge St. Mary School System may: not allow further attendance of classes/activities and/or withhold transcripts/academic records. Non-Payment of Tuition: In case of default of payment to St. Mary School System, I agree to pay all costs of collection including attorney fees, collections fees, and contingent fees to collection agencies.

Required

By submitting this registration form, I hereby warrant to St. Mary School System and/or After School Program that I am entitled to legal custody and possession of my child(ren) and am authorized to complete this form. Additionally, I have read and understand this form. In consideration, I agree to hold harmless and indemnify the St. Mary School System and its employees against all injuries arising out of these arrangement.