Registration

Child/Children Information REQUIRED Please fill out this field.
Child 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED M F Please fill out this field.
- Date of Birth mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- SS# REQUIRED Please fill out this field. Please enter valid data.
- Child would otherwise attend what school? REQUIRED Please fill out this field. Please enter valid data.
- In what Public School System? REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of Baptism REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of First Communion Please enter valid data.
- Name & Location of School Last Attended Please enter valid data.
- Special Education services received Please enter valid data.
Child 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED M F Please fill out this field.
- Date of Birth mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- SS# REQUIRED Please fill out this field. Please enter valid data.
- Child would otherwise attend what school? REQUIRED Please fill out this field. Please enter valid data.
- In what Public School System? REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of Baptism REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of First Communion Please enter valid data.
- Name & Location of School Last Attended Please enter valid data.
- Special Education services received Please enter valid data.
Child 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED M F Please fill out this field.
- Date of Birth mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- SS# REQUIRED Please fill out this field. Please enter valid data.
- Child would otherwise attend what school? REQUIRED Please fill out this field. Please enter valid data.
- In what Public School System? REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of Baptism REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of First Communion Please enter valid data.
- Name & Location of School Last Attended Please enter valid data.
- Special Education services received Please enter valid data.
Child 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED M F Please fill out this field.
- Date of Birth mm/dd/yyyy REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent’s Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- SS# REQUIRED Please fill out this field. Please enter valid data.
- Child would otherwise attend what school? REQUIRED Please fill out this field. Please enter valid data.
- In what Public School System? REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of Baptism REQUIRED Please fill out this field. Please enter valid data.
- Date & Location of First Communion Please enter valid data.
- Name & Location of School Last Attended Please enter valid data.
- Special Education services received Please enter valid data.

Mother Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Maiden Name Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
State of Birth REQUIRED Please fill out this field. Please enter valid data.
Educational Status REQUIRED Please fill out this field. Please enter valid data.
Occupation REQUIRED Please fill out this field. Please enter valid data.
Employed By REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Marital Status REQUIRED Please fill out this field. Please enter valid data.
Step-Parents (if applicable) Please enter valid data.
With whom child resides Please enter valid data.
Religion Please enter valid data.
Parish Please enter valid data.

Father Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
State of Birth REQUIRED Please fill out this field. Please enter valid data.
Educational Status REQUIRED Please fill out this field. Please enter valid data.
Occupation REQUIRED Please fill out this field. Please enter valid data.
Employed By REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Marital Status REQUIRED Please fill out this field. Please enter valid data.
Step-Parents (if applicable) Please enter valid data.
With whom child resides Please enter valid data.
Religion Please enter valid data.
Parish Please enter valid data.

Signature (Type Name) of Person Registering Child REQUIRED Please fill out this field. Please enter valid data.

Relationship to Child REQUIRED Please fill out this field. Please enter valid data.

Names and Birth Dates of brothers and sisters living at home

New Students: How did you hear about St. Mary’s School? (Circle all that apply) Web Site Newspaper Mailing Billboard Movie Theater Friend/Family Member Other

If Friend/Family Member or other, please explain: Please enter valid data.

All information provided by me on this form is true and complete to the best of my knowledge.

Non-Refundable Registration Fee due at time of registration. 2021-2022

Emergency Medical Form

Child’s/Children’s LAST Name REQUIRED Please fill out this field. Please enter valid data.
Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Cell Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Cell Number Maximum 20 characters Please enter a phone number.
E-mail Address REQUIRED Please fill out this field. Please enter an email address.
List all Children at St. Mary’s School: (Preschool state P3, P4, or P5) REQUIRED Please fill out this field.
Medical Problem Explanation

Adults Legally Responsible

Mother(step) REQUIRED Please fill out this field. Please enter valid data.
Father(step) REQUIRED Please fill out this field. Please enter valid data.
Guardian Please enter valid data.
Address REQUIRED Please fill out this field.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Father’s Place of Work Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Mother’s Place of Work Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Church Family Attends and Supports Please enter valid data.

In case of emergency and Parents Cannot be reached, call:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Family Doctor’s Name REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
In an emergency, your hospital preference is Please enter valid data.
Your child(ren) arrives every day with Please enter valid data.
Child(ren) ride the bus Yes No
Your child(ren) departs every day with Please enter valid data.
I give my permission for the following people to pick up my child(ren)from school: REQUIRED Please fill out this field.
My child(ren) may not depart with:
Parent Signature(s) REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

St. Mary’s School Tuition Payment Option Form

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Address REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
List Student Name(s) & Grade Level 2021-2022 REQUIRED Please fill out this field.

St. Mary’s School Tuition for the 2021-2022 School year

Grades TK-8

Catholic	1-child	2-children	3+ children
Annual Cost	$3,000	$4,940	$6,710
Monthly Payment (10 months)	300	494	671

Grades TK-8

Non-Catholic	1-child	2-children	3+ children
Annual Cost	$4,010	$7,420	$10,280
Monthly Payment (10 months)	401	742	1,028

Preschool	Annual Cost	Monthly Payment
2 (P3) Two Half Days	$1,501.50	$150.15
2 (P3) Two Full Days	$1,980.00	$198.00
3 (P4) Three Half Days	$1,633.50	$163.35
3 (P4) Three Full Days	$2,530.00	$253.00
5 (P5) Five Half Days	$2,167.00	$216.70
5 Full Days for 4 and 5 year olds	$3,234.00	$323.40

Registration Fee:

$50 per Family by May 3
$75 per Family after May 3
$100 per Family beginning 1^st Day of school 2021-2022

Administrative Fee:

$25.00 New Families of school 2021-2022

Technology Fee:

Included in tuition

Please check the option below that best suits your needs. By signing this document, you agree to pay the amount due according to the conditions outlined in the three options.. REQUIRED Option 1: Full payment by August 1st Option 2: Automatic Withdrawal (Quarterly, Monthly) please mark one below Option 3: Monthly payment due at the end of each month (10 months of Sept.-June) Please fill out this field.
Option 2: Circle One Monthly Quarterly
Option 2: St. Mary’s School will send the necessary form to be completed by you. Also select desired date of month or quarter for withdrawal Please enter valid data.
Parent Signature REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

In order to be compliant in the National Catholic Education Association (NCEA)

We need to have the following student enrollment data for reporting purposes. Please complete both Parts A and B. Otherwise, the school must supply an answer on your behalf.

Student's Name REQUIRED Please fill out this field. Please enter valid data.

Grade REQUIRED Please fill out this field. Please enter valid data.

Part A.

Is this student Hispanic/Latino? (Choose only One) REQUIRED No, not Hispanic/Latino Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race) Please fill out this field.
Part A. of the question is about ethnicity, not race. Regardless of what you selected in Part A, please answer Part B by marking one or more boxes to indicate what you consider your race to be.

Part B.

What is the student's race? (Choose one or more) American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America including Central America) Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam) Black or African-American (A person having origins in any of the black racial groups of Africa) Native Hawaiian or Other Pacific Islander(A person having origins in any of the original peoples ofHawaii, Guam, Samoa or other Pacific Islands) White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa)

Parent Signature: REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Home Language Survey

Family Name REQUIRED Please fill out this field. Please enter valid data.
Apellido REQUIRED Please fill out this field. Please enter valid data.
What is the main language spoken in the home? Que idioma se habla en el hogar? Español/Spanish Ingles/English Otro/Other