SMA Online Application

School Year Applying For REQUIRED Please fill out this field.

Parental/Guardian Information

Parent Guardian 1 REQUIRED Please fill out this field. Please enter valid data.

Parent Email Address REQUIRED Please fill out this field. Please enter valid data.

Parent Guardian 2 Please enter valid data.

Parent 2 Email Address REQUIRED Please fill out this field. Please enter valid data.

Parent Guardian 1 Relationship (Mother, Father, Step-parent, Guardian, Grandparent, Deceased) REQUIRED Please fill out this field. Please enter valid data.

Parent Guardian 2 Relationship (Mother, Father, Step-parent, Guardian, Grandparent, Deceased) Please enter valid data.

Parent Guardian 1 Marital Status* (Married, Single, Widowed, Divorced, Remarried, Separated) REQUIRED Please fill out this field. Please enter valid data.

Parent Guardian 2 Marital Status* (Married, Single, Widowed, Divorced, Remarried, Separated) Please enter valid data.

Street Address REQUIRED Please fill out this field. Please enter valid data.

Street Address 2 Please enter valid data.

City, State, Zip Code REQUIRED Please fill out this field. Please enter valid data.

Home Phone 1 REQUIRED Please fill out this field. Please enter valid data.

Home Phone 2 Please enter valid data.

Work Phone Please enter valid data.

Religion Please enter valid data.

Parent Guardian 1 Employer Please enter valid data.

Parent Guardian 2 Employer Please enter valid data.

Parent Guardian 1 Occupation Please enter valid data.

Parent Guardian 2 Occupation Please enter valid data.

Language(s) Spoken In Home Please enter valid data.

Names and birth dates of ALL children in family (list pre-school children first)

Boys

Girls

Custody (if applicable) Single Joint

Name(s) Please enter valid data.

If you and the physician of your choice cannot be reached in an emergency and, if in the judgement of the school authorities, immediate medical and/or hospital attention is indicated, do you authorize the school authorities to send your child (properly accompanied) to an available hospital or physician?

Choose one Yes No

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

As a parent and/or guardian, I authorize the treatment of a minor child/children by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger child’s life, cause physical disability or undue discomfort if delayed.

This consent is granted only after reasonable effort has been made to reach me.

Choose one Yes No

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

Student 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.

Date-of-Birth REQUIRED Please fill out this field. Please enter valid data.

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

Birth City/State/Country Please enter valid data.

Gender REQUIRED Male Female Please fill out this field.

Oldest Child? REQUIRED Yes No Please fill out this field.

First Language Child Learned to Speak? Please enter valid data.

Language Child Speaks Most Often? Please enter valid data.

Current Parish? REQUIRED Please fill out this field. Please enter valid data.

Pre-School (3-4 years old, child must be 3 by 8/1 and full toilet trained) 3 Days (T, W, Th) 5 days (M-F)

Pre-Kindergarten (4-5 years old)
5 days (M-F), students must be 4 by 8/1 and fully toilet trained

(PreSchool/PreK Only) Has your child attended a program in the past? Yes No

(PreSchool/PreK Only) Reason For Leaving Please enter valid data.

After School The Child Goes to? (Note: This will not register your child for SMA After School Care) REQUIRED Please fill out this field. Please enter valid data.

After School Number REQUIRED Please fill out this field. Please enter valid data.

After School Contact REQUIRED Please fill out this field. Please enter valid data.

Religious Records

Baptism

Date Please enter valid data.
Church Please enter valid data.
City, State, Zip Code Please enter valid data.

First Eucharist

Date Please enter valid data.
Church Please enter valid data.
City, State, Zip Code Please enter valid data.

First Reconciliation

Date Please enter valid data.
Church Please enter valid data.
City, State, Zip Code Please enter valid data.

Confirmation

Date Please enter valid data.
Church Please enter valid data.
City, State, Zip Code Please enter valid data.

Medical Information

First Contact

Name REQUIRED Please fill out this field. Please enter valid data.
Relation REQUIRED Please fill out this field. Please enter valid data.
Phone REQUIRED Please fill out this field. Please enter valid data.

Second Contact

Name REQUIRED Please fill out this field. Please enter valid data.
Relation REQUIRED Please fill out this field. Please enter valid data.
Phone REQUIRED Please fill out this field. Please enter valid data.

Doctor

Name REQUIRED Please fill out this field. Please enter valid data.
Address REQUIRED Please fill out this field. Please enter valid data.
City, State, Zip Code REQUIRED Please fill out this field. Please enter valid data.
Phone REQUIRED Please fill out this field. Please enter valid data.
Preferred Hospital REQUIRED Please fill out this field.
Hospital Address REQUIRED Please fill out this field. Please enter valid data.
Hospital City, State, Zip Code REQUIRED Please fill out this field. Please enter valid data.

Health or Physical Limitations (if none say N/A) REQUIRED Please fill out this field.

Medications (if none say N/A) REQUIRED Please fill out this field.

Instructions (if none say N/A) REQUIRED Please fill out this field.

Allergies (if none say N/A) REQUIRED Please fill out this field.

Immunization Expiration Date (mm/dd/yyyy) Please enter valid data.

Transfer Information

School Please enter valid data.
Address Please enter valid data.
Date Entered Please enter valid data.
Date Withdrew Please enter valid data.

Reason Code 1. Completed Program 2. Moved 3. Illness 4. Parent Choice 5. Other

Please indicate if your child has ever been evaluated for, and/or, participated in the following: Speech Occupational Therapy Counseling IEP/504 Plan SSP or SAP Reading Intervention Math Intervention First Steps

Does this child currently receive any special services as listed above? Yes No

Current Teacher Please enter valid data.

Phone Please enter valid data.

Email Please enter valid data.

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