Private School Confirmation Registration

Please complete the form below. Required fields marked with an asterisk *

Family Last Name*

Answer required for "Family Last Name"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Home Phone Number

Number Required

Father's Name*

Answer required for "Father's Name"

Father's Work Phone

Number Required

Father's Cell*

Number Required

Father's Email Address*

Answer required for "Father's Email Address"

Mother's Name*

Answer required for "Mother's Name"

Mother's Work Phone

Number Required

Mother's Cell *

Number Required

Mother's Email Address*

Answer required for "Mother's Email Address"

Is your family registered in the parish?*

Answer required for "Is your family registered in the parish?"

Yes

If not, where are you registered?*

Answer required for "If not, where are you registered?"

Child's Name*

Answer required for "Child's Name"

Child's Age*

Answer required for "Child's Age"

Child's Grade*

Answer required for "Child's Grade"

Is the child new to St. Clement of Rome?*

Answer required for "Is the child new to St. Clement of Rome?"

Yes

Child's Name*

Answer required for "Child's Name"

Child's Age*

Answer required for "Child's Age"

Child's Grade*

Answer required for "Child's Grade"

Is the child new to St. Clement of Rome?*

Answer required for "Is the child new to St. Clement of Rome?"

Yes

NEW STUDENTS - PLEASE PRESENT A COPY OF STUDENT BAPSTIMAL CERTIFICATE WITH REGISTRATION.

Tuition - $50.00 per child

Emergency Information

In case of serious accident or serious illness, I request the school contact me. By clicking YES below, I hereby authorize the school to call the physician indicated below and follow his instructions. If it is impossible to contact the physician, the school may make the appropriate arrangements for the care of my child.*

Answer required for "In case of serious accident or serious illness, I request the school contact me. By clicking YES below, I hereby authorize the school to call the physician indicated below and follow his instructions. If it is impossible to contact the physician, the school may make the appropriate arrangements for the care of my child."

Yes - I consent

No - I do not consent

Physician's Information

Physician's Name*

Answer required for "Physician's Name"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Office Phone*

Number Required

Home/Exchange Phone*

Number Required

Hospital*

Answer required for "Hospital"

Name two neighbors or relatives who will assume temporary care of your child if you cannot be reached.

Name*

Answer required for "Name"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Mobile Phone*

Number Required

Name*

Answer required for "Name"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Mobile Phone*

Number Required

Do any of your children receive any Special Services at their school or after hours?*

Answer required for "Do any of your children receive any Special Services at their school or after hours?"

Yes

If yes, please explain below. If no, then write none.*

Answer required for "If yes, please explain below. If no, then write none."

Do any of your children have special medical needs or are on any medications?*

Answer required for "Do any of your children have special medical needs or are on any medications?"

Yes

If yes, please explain below. If no, then write none.*

Answer required for "If yes, please explain below. If no, then write none."

Please fix the highlighted areas below before submitting.

Private School Confirmation Registration