Please complete the entire form. If you have any questions regarding this form, please contact Christy Toben, Principal, or Ms. Minette Blair, Secretary, at (314) 389-0401. (All questions marked with * must be completed.) Student Information Grade Applying To * - Select -K1st2nd3rd4th5th6th7th8th First Name * Middle Name * Last Name * Home Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Home Phone * Birth Date * Year20072008200920102011201220132014201520162017201820192020202120222023 Year MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Social Security Number Gender * - Select -MaleFemale Religion * Church Attending (if applicable) Pastor Describe the family situation (please check all that apply) * Married Single Separated Divorced Deceased Father has custody* Mother has custody* Joint custody* Guardian has custody* * If applicable, please submit a copy of the court-mandated parenting plan with the application. Student lives with (please check all that apply) * Both parents/guardians Mother Father Mother/Stepfather Father/Stepmother Grandparent(s) Other The following information is optional (please check all that apply) African African-American Asian Caucasian (White) Hispanic Other Primary Language Spoken at Home * Person(s) responsible for tuition * Public school district in which the family resides * Public school student would attend in district * Father/Guardian Information Full Name Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Home Phone Cell Phone Work Phone Email Address Employer & Position Mother/Guardian Information Full Name Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Home Phone Cell Phone Work Phone Email Address Employer & Position Sibling Information Name / Grade / School Name / Grade / School Name / Grade / School Medical Information Student's Physician and Phone * Student's Dentist and Phone * Hospital where student should be taken if parent or physician is unavailable * Allergies and Other Medical Conditions * Allergies Food Allergies Asthma Diabetes Epilepsy Heart Problems Recurring Illness Other Medical Concerns (check all that apply) Allergies and Other Medical Concerns * Medications to be taken at school Emergency Contact Emergency Contact #1 * Emergency Contact #2 * Additional Information Please describe any special educational needs that your child may have. Does this student have an IEP? * Yes No If 'Yes' we will need a copy of the IEP for our records. Please briefly indicate why you are seeking to transfer your child to this school. * Statement of Confidentiality It is the policy of this school that all information received regarding an applicant’s application will be treated with complete confidentiality. Only authorized school personnel have access to such information. Non Discrimination Policy St. Louis Catholic Academy will admit students of any race, religion, color, or national and ethnic origin to all rights, privileges, programs, and activities generally accorded or made available to our school. This school will not discriminate on the basis of race, religion, color, or national and ethnic origin in admission policies, scholarships, athletic, and other school administered programs. Completing Admissions Process Upon receipt of this application, the school will contact your family about completing the admissions process. 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