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JAMES L.COLLINS CATHOLIC SCHOOL STUDENT REGISTRATION 2017-2018

PLEASE PRINT ALL INFORMATION

STUDENT INFORMATION

DATE OF APPLICATION ______GRADE ENTERING______

Student’s Name ______Last First Middle Preferred Name

______Male ______Female Date of Birth ______Place of Birth ______

Social Security Number ______Home Phone ______

Home Address ______Street City State Zip

Ethnicity (Check One) Hispanic ______Not Hispanic______

Race (Circle One) * Black/African American * White * Asian Native Hawaiian/Pacific Islander * Two or more races * American Indian/Native Alaskan

Religion ______Present Parish______Student Sacramental History

Baptismal Date______Parish ______City & State______

Reconciliation Date ______Parish______City & State______

First Communion Date______Parish ______City & State______

SCHOOL HISTORY Schools attended (List most current first)______

Public School Zone (Public School your child would attend) ______

Has your child ever been retained? If yes, what grade? ______

Has your child ever been diagnosed with a learning disability, attention deficit disorder, attention deficit disorder with hyperactivity, central auditory processing disorder? Explain______

If yes, is there documentation to verify diagnosis______

Has your child ever received educational diagnostic testing? ______

Has your child had an IEP (Individual Education Plan)? ______

Does your child have any other special needs/disabilities? Please explain: ______

James L. Collins Catholic School 3000 W Hwy 22  Corsicana, TX 75110  903-872-1751 www.CollinsCatholicSchool .com  [email protected] JAMES L.COLLINS CATHOLIC SCHOOL STUDENT REGISTRATION 2017-2018

FAMILY INFORMATION

Student currently lives with: (Circle One) Both Parents * * Mother ** Father ** Guardian Parents are: (Circle One) Married ** Divorced ** Remarried ** Single

If parents are divorced, who has primary custody? ______DOCUMENTATION OF CUSTODY MUST BE GIVEN AT TIME OF REGISTRATION

Who should receive school communications? ______

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Father’s Name ______Last First Middle Address (If different from Student’s) ______

Home Phone ______Cell Phone ______Work ______

Email Address ______Religion ______Occupation______

Are you an Alumnus of James L. Collins Catholic School? ______Year Graduated______

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Mother’s Name ______Last First Middle

Address (If different from Student’s) ______

Home Phone ______Cell Phone ______Work ______

Email Address ______Religion ______Occupation______

Are you an Alumnus of James L. Collins Catholic School? ______Year Graduated______

Please list other children in the family: Name Age School ______

Are you a member of Immaculate Conception Catholic Church (officially registered and contributing)? Yes ______No ______

James L. Collins Catholic School 3000 W Hwy 22  Corsicana, TX 75110  903-872-1751 www.CollinsCatholicSchool .com  [email protected]