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New Family Application

- The maximum number of form submissions has been reached. This form is currently not available.
  
  New Family Application
  You may complete one Application Form
  to enroll multiple children from the same family.
  
  Anticipated Start Date REQUIRED Current Term Upcoming August ( beginning of Quarter 1) Upcoming January (beginning of Quarter 3) Please fill out this field.
  
  Best Email Contact REQUIRED Please fill out this field. Please enter an email address.
  
  ________________________________________________________________________________________
  STUDENT INFORMATION
  
  Child's Home Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Home City REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Home State REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Home Zip Code REQUIRED Please fill out this field. Please enter valid data.
  
  ________________________________________________________________________________________
  
  Number of Children Registering REQUIRED Please fill out this field.
  
  Child 1
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 2
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 3
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 4
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 5
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 6
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 7
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 8
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 9
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  Child 10
  
  Child's Birth Certificate First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Middle Name Please enter valid data.
  
  Child's Birth Certificate Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Birth Certificate Suffix Please enter valid data.
  
  Child's Preferred Nickname Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Enrolling at St. Susanna in Grade Level REQUIRED Please fill out this field.
  
  What school is your child currently attending? REQUIRED Please fill out this field. Please enter valid data.
  
  STUDENT STATE REPORTING
  St. Susanna School provides total Catholic education for all students without regard to gender, race, ethnicity, socio-economic status, language, religion, or ability. The following questions gather information necessary to complete state and federal reporting requirements.
  
  Child's Gender REQUIRED Male Female Please fill out this field.
  
  Child's Religion REQUIRED Catholic Non-Catholic Please fill out this field.
  
  Name of Parish/Church Membership REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Ethnicity REQUIRED Hispanic or Latino Non-Hispanic/Latino Please fill out this field.
  
  Child's Race (check all that apply) REQUIRED American Indian or Alaskan Native Black or African American Asian White Native Hawaiian/Other Pacific Islander Please fill out this field.
  
  Home Language Survey Yes, the native language of the student, the language(s) most often spoken by the student, or the language(s) spoken by the student in the home is a language other than English. No, English-speaking only
  
  If you answered YES above, please list languages spoken Please enter valid data.
  
  Student Medical Background
  
  List all Daily Prescription Medications Please enter valid data.
  
  List Allergies Please enter valid data.
  
  List any Medical Concerns
  
  Student Educational Background
  
  Does your child have an Individual Education Plan (IEP) or a 504 Plan? REQUIRED Yes, Please provide a copy of this documentation. No, my child does not have an IEP or 504 Plan. Please fill out this field.
  
  If Special Educational needs, please describe
  
  Disciplinary Record REQUIRED Yes, my child has a disciplinary record but has not been suspended or expelled. Yes, my child has been suspended or expelled. No, my child does not have a disciplinary record. Please fill out this field.
  
  If Discplinary Record, please describe
  
  ___________________________________________________________________________
  FAMILY INFORMATION
  
  Home School District of Residence where children reside REQUIRED Please fill out this field. Please enter valid data.
  
  County of Residence REQUIRED Please fill out this field. Please enter valid data.
  
  Neighborhood or Nearest Cross Roads of Residence Please enter valid data.
  
  List Siblings Not Attending St. Susanna School (Name, Age, Current School)
  
  Child lives with REQUIRED Please fill out this field.
  
  Primary Parent Contact-Which parent should we contact first for school concerns, illness, or injury? REQUIRED Please fill out this field.
  
  ___________________________________________________________________________
  FATHER'S INFORMATION
  
  Please provide complete information. It is important that phone numbers and email addresses be correct and complete as we use this information for emergency contacts and daily communications. Thank you!
  
  Father's First Name Please enter valid data.
  
  Father's Last Name Please enter valid data.
  
  Father's Cell Phone Maximum 20 characters Please enter a phone number.
  
  Father's Home Phone Maximum 20 characters Please enter a phone number.
  
  Father's Work Phone Maximum 20 characters Please enter a phone number.
  
  Father's Home Email Please enter an email address.
  
  Father's Work Email Please enter an email address.
  
  Father's Employer Please enter valid data.
  
  Father's Occupation Please enter valid data.
  
  Father's Street Address (if different than child) Please enter valid data.
  
  Father's City (if different than child) Please enter valid data.
  
  Father's State (if different than child) Please enter valid data.
  
  Father's Zip (if different than child) Please enter valid data.
  
  ___________________________________________________________________________
  MOTHER'S INFORMATION
  
  Please provide complete information. It is important that phone numbers and email addresses be correct and complete as we use this information for emergency contacts and daily communications. Thank you!
  
  Mother's First Name Please enter valid data.
  
  Mother's Last Name Please enter valid data.
  
  Mother's Cell Phone Maximum 20 characters Please enter a phone number.
  
  Mother's Home Phone Maximum 20 characters Please enter a phone number.
  
  Mother's Work Phone Maximum 20 characters Please enter a phone number.
  
  Mother's Home Email Please enter an email address.
  
  Mother's Work Email Please enter an email address.
  
  Mother's Employer Please enter valid data.
  
  Mother's Occupation Please enter valid data.
  
  Mother's Street Address (if different than child) Please enter valid data.
  
  Mother's City (if different than child) Please enter valid data.
  
  Mother's State (if different than child) Please enter valid data.
  
  Mother's Zip (if different than child) Please enter valid data.
  
  ___________________________________________________________________________
  GUARDIAN #1 INFORMATION
  (Please complete this section if child does not live with a mother or father.)
  
  Guardian #1 First Name Please enter valid data.
  
  Guardian #1 Last Name Please enter valid data.
  
  Guardian #1 Relationship to Child
  
  Guardian #1 Cell Phone Maximum 20 characters Please enter a phone number.
  
  Guardian #1 Home Phone Maximum 20 characters Please enter a phone number.
  
  Guardian #1 Work Phone Maximum 20 characters Please enter a phone number.
  
  Guardian #1 Home Email Please enter an email address.
  
  Guardian #1 Work Email Please enter an email address.
  
  Guardian #1 Employer Please enter valid data.
  
  Guardian #1 Occupation Please enter valid data.
  
  Guardian #1 Street Address Please enter valid data.
  
  Guardian #1 City Please enter valid data.
  
  Guardian #1 State Please enter valid data.
  
  Guardian #1 Zip Please enter valid data.
  
  ___________________________________________________________________________
  GUARDIAN #2 INFORMATION
  (Please complete this section if child does not live with a mother or father
  and you would like to add information for an additional guardian.)
  
  Guardian #2 First Name Please enter valid data.
  
  Guardian #2 Last Name Please enter valid data.
  
  Guardian #2 Relationship to Child
  
  Guardian #2 Cell Phone Maximum 20 characters Please enter a phone number.
  
  Guardian #2 Home Phone Maximum 20 characters Please enter a phone number.
  
  Guardian #2 Work Phone Maximum 20 characters Please enter a phone number.
  
  Guardian #2 Home Email Please enter an email address.
  
  Guardian #2 Work Email Please enter an email address.
  
  Guardian #2 Employer Please enter valid data.
  
  Guardian #2 Occupation Please enter valid data.
  
  Guardian #2 Street Address Please enter valid data.
  
  Guardian #2 City Please enter valid data.
  
  Guardian #2 State Please enter valid data.
  
  Guardian #2 Zip Please enter valid data.
  
  ___________________________________________________________________________
  EMERGENCY CONTACTS
  (when we are NOT able to reach a parent)
  PLEASE PROVIDE AT LEAST 2 CONTACTS OTHER THAN THE PARENTS.
  
  Contact #1 (Last Name, First Name) Please enter valid data.
  
  Contact #1-- Relationship to Child
  
  Contact #1 Cell Phone Please enter valid data.
  
  Contact #1 Home Phone Please enter valid data.
  
  Contact #1 Work Phone Please enter valid data.
  
  ___________________________________________________________________________
  
  Contact #2 (Last Name, First Name) Please enter valid data.
  
  Contact #2-- Relationship to Child
  
  Contact #2 Cell Phone Please enter valid data.
  
  Contact #2 Home Phone Please enter valid data.
  
  Contact #2 Work Phone Please enter valid data.
  
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  Contact #3 (Last Name, First Name) Please enter valid data.
  
  Contact #3-- Relationship to Child
  
  Contact #3 Cell Phone Please enter valid data.
  
  Contact #3 Home Phone Please enter valid data.
  
  Contact #3 Work Phone Please enter valid data.
  
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  ADDITIONAL INFORMATION & ASSURANCES
  
  INDIANA DEPARTMENT OF EDUCATION MIGRANT WORKER SURVEY
  The Migrant Education Program (MEP) provides supplemental education and support services to eligible children through national funding. The purpose of the program is to ensure that all migrant students reach the academic standards and graduate with high school diploma (or complete GED/HSE). The Indiana Department of Education requires that we identify these students by asking the following two questions.
  
  Work Survey #1 REQUIRED Yes, my children have moved (for any reason) within the last 3 years. No, my children have NOT moved (for any reason) within the last 3 years. Please fill out this field.
  
  Work Survey #2 REQUIRED Yes, someone in my household has moved from one school district to another within the United States to look for seasonal or temporary work in agriculture. No, no one in my household has moved from one school district to another within the United States to look for seasonal or temporary work in agriculture Please fill out this field.
  
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  SCHOOL POLICY ACCEPTANCE
  Each year our school policies and procedures are reviewed, amended, and approved by our school principal and School Commission. We ask all families to review and accept the Parent & Student Handbook which includes the School Uniform Policy, the Acceptable Use Policy, Health & Wellnesss Policy, and the Attendance Policy. These policies are posted on the school website. Please indicate that you will review the Parent & Student Handbook and abide by all policies of St. Susanna School.
  
  School Policy Acceptance REQUIRED Yes, I will review with my child the Parent & Student Handbook including the Attendance Policy, Acceptable Use Policy, Health & Wellness Policy, and Uniform Policy and we will abide by all policies set forth. No, I need to discuss a policy concern with the school principal. Please fill out this field.
  
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  MEDIA RELEASE STATEMENT
  We believe that our students, staff, and school benefit from positive recognition. There may be occasions for media coverage during the school year that involves our students. We ask permission to release pictures or other communication to the medica, should the opportunity arise. This may include, but would not be limited to: newspapers, news station coverage of events, our newsletter, bulleting boards, videos made during the school year, and our school website. Please indicate whether you do or do not grant permission.
  
  Authorize Media Release REQUIRED Yes, I grant permission. No, I DO NOT grant permission. Please fill out this field.
  
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  PARISH PESTICIDE REGISTRY
  Indiana State Law requires St. Susanna School to invite parents, guardians, & staff to be added to the pesticide registry at the start of each school year or when a student enrolls or transfers in. If you wish to be contacted via email 48 hours in advance of planned pesticide applications (such as yard fertilization or pest applications) on the parish campus, please complete a Pesticide Notification Registry Form at the reception desk.
  
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  REGISTRATION FEE
  Registration Fee is $100 per student and must be paid to secure placement in a class. The fee is non-refundable and will not be applied to any fees. Online enrollment without accompanying registration fee payments will not be processed. Plans for space allocation, classroom placement, and faculty assignments will be decided one registration figures are finalized.
  
  Method of Payment of Registration Fee REQUIRED Check--please remit to school receptionist or mail to St. Susanna School 1212 East Main Street, Plainfield, IN 46168 Cash (exact amount)--please remit in-person to school receptionist. Pay Online--VISA, MC, Account transfer (no additional bank fees added) Please contact me about payment arrangements. We are a CHOICE Family. Please fill out this field.
  
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  ENROLLMENT REQUEST
  
  Why have you chosen to enroll your child at St. Susanna School?
  
  If you were referred to St. Susanna School, whom may we thank for your referral? Please enter valid data.
  
  If there is additional information you would like to provide, please add it here.
  
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  Thank you for completing our Family Application. Please click the submit below and you will receive an email verification of submission and next steps to complete the Application Process.
  
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