<p> JAMES L.COLLINS CATHOLIC SCHOOL STUDENT REGISTRATION 2017-2018</p><p>PLEASE PRINT ALL INFORMATION</p><p>STUDENT INFORMATION</p><p>DATE OF APPLICATION ______GRADE ENTERING______</p><p>Student’s Name ______Last First Middle Preferred Name</p><p>______Male ______Female Date of Birth ______Place of Birth ______</p><p>Social Security Number ______Home Phone ______</p><p>Home Address ______Street City State Zip</p><p>Ethnicity (Check One) Hispanic ______Not Hispanic______</p><p>Race (Circle One) * Black/African American * White * Asian Native Hawaiian/Pacific Islander * Two or more races * American Indian/Native Alaskan </p><p>Religion ______Present Parish______Student Sacramental History</p><p>Baptismal Date______Parish ______City & State______</p><p>Reconciliation Date ______Parish______City & State______</p><p>First Communion Date______Parish ______City & State______</p><p>SCHOOL HISTORY Schools attended (List most current first)______</p><p>Public School Zone (Public School your child would attend) ______</p><p>Has your child ever been retained? If yes, what grade? ______</p><p>Has your child ever been diagnosed with a learning disability, attention deficit disorder, attention deficit disorder with hyperactivity, central auditory processing disorder? Explain______</p><p>If yes, is there documentation to verify diagnosis______</p><p>Has your child ever received educational diagnostic testing? ______</p><p>Has your child had an IEP (Individual Education Plan)? ______</p><p>Does your child have any other special needs/disabilities? Please explain: ______</p><p>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</p><p>FAMILY INFORMATION</p><p>Student currently lives with: (Circle One) Both Parents * * Mother ** Father ** Guardian Parents are: (Circle One) Married ** Divorced ** Remarried ** Single</p><p>If parents are divorced, who has primary custody? ______DOCUMENTATION OF CUSTODY MUST BE GIVEN AT TIME OF REGISTRATION</p><p>Who should receive school communications? ______</p><p>*********************************************</p><p>Father’s Name ______Last First Middle Address (If different from Student’s) ______</p><p>Home Phone ______Cell Phone ______Work ______</p><p>Email Address ______Religion ______Occupation______</p><p>Are you an Alumnus of James L. Collins Catholic School? ______Year Graduated______</p><p>***************************************************</p><p>Mother’s Name ______Last First Middle</p><p>Address (If different from Student’s) ______</p><p>Home Phone ______Cell Phone ______Work ______</p><p>Email Address ______Religion ______Occupation______</p><p>Are you an Alumnus of James L. Collins Catholic School? ______Year Graduated______</p><p>Please list other children in the family: Name Age School ______</p><p>Are you a member of Immaculate Conception Catholic Church (officially registered and contributing)? Yes ______No ______</p><p>James L. Collins Catholic School 3000 W Hwy 22  Corsicana, TX 75110  903-872-1751 www.CollinsCatholicSchool .com  [email protected]</p>