School Student Enrollment Form

Student Data

Student Name


Home Address

, ,

Home Phone

Date of Birth

Place of Birth

Social Security Number

Ethic Background (optional)

Grade Entering
Please note: Kindergarten Sessions are All Day Monday through Friday.

Last School Attended

PUBLIC School District where student resides

PUBLIC School Name

Health Information

Does this student have specific medical needs of which we should be aware (eyeglasses, allergies, etc)?
If Yes, please describe:

Does this student require medication during regular school hours?
If Yes, please list medication name and dosage:

Parish Data

Child's Sacraments Date Church Pastor's Name
First Eucharist

Current Church Affiliation

Pastor's Name

Related Information

Is there any additional information concerning this student regarding any specific learning challenges (i.e. prior testing, learning difficulties, emotional concerns, gifted student, etc)?
If yes, please indicate:

Has this student ever been expelled from school?
If yes, please list school and details:

Has this student been retained in a grade?
If yes, please list which grade and a brief explanation:

Family Data

Question Father Mother Step-Father Step-Mother
Maiden Name
Language Spoke in Home
Religious Affliliation
Marital Status
Name of Spouse
Child resides with whom?
Birthplace State
Place of Employment
Work Phone
Cell Phone
Email Address
Driver’s License #
Social Security #
Date of Birth

Parent Information

Question Father Mother Step-Father Step-Mother
Have you been convicted of a sex crime?
Are you listed on any sex offender registry?
Have you been convicted of a "listed offense" as defined under Michigan Law?

Children in the Family

Name Birthday School Grade Level

I understand that failure to provide complete and accurate information to school administrators may be cause for dismissal from the school.

Registration Fees:
Kindergarten: $700.00 All Day M-F, $200 (non-refundable) due at registration, remainder due by September 1.
Grade 1-8: $700 due by September 1
Families must contract with "Smart Tuition" for any unpaid balance as of September 1.

Parent Signature: