Registration Form

Student Information

Preschool: Please check:

Preschool: Please check:3/4 year old split classroom-3 full days3 year old classroom- 5 full days4 year old classroom- 5 full days

Grade:K12345678

Name:

Date of Birth:

Gender:Please selectMaleFemale

Religion: CatholicPlease selectYesNo

Baptism Date:

Church of Baptism:

Do you intend to have your child participate in the Sacraments at Queen of the Rosary School? (Reconciliation, First Communion, and Confirmation)?Please selectYesNo

Registered Parishioner of:

Ethnicity : Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Yes, Hispanic/LatinoNo, not Hispanic/Latino

Race:N = American IndianB = Black or African AmericanM = Multi-racialP = Native Hawaiian/Pacific IslanderW = White

Last School Attended:

Would attend public school at:

Resides in public district #:

Has your child ever been recommended for special education testing:Please selectYesNoIf yes, please explain:

Has retention of your child ever been suggested or discussed:Please selectYesNoIf yes, please explain:

Does your child have any special needs that Queen of the Rosary should be aware of? (i.e.: medical or academic):Please selectYesNoIf yes, please explain:

Will your child be a District 59 bus rider? (Must live more than 1 1/2 miles away and in District 59.)Please selectYesNo

Please select one in each column:

Student Lives With:1=Both Parents2=Mother Only3=Mother & Stepfather4=Father Only5=Father & Stepmother6=Legal Guardian7=Foster Parent8=Other9=Both Parents, Dual Residency

Custody:

1=Both Parents2=Mother3=Father4=Other5=Joint (Separated with Shared Custody)

Title:

1=Mr. & Mrs.2=Mrs.3=Mr.4=Ms.5=Miss

Relationship:

1=Mother/Father2=Grandparents3=Aunt/Uncle4=Brother/Sister5=Neighbor6=Family Friend7=Guardian

Parent Information:

Please check appropriate box and fill out information for that person:

FatherStepfatherGuardian

Last Name:

First Name:

Cell Phone:

Email:

Religion:

Employed by:

Occupation:

Business Address:

Work Phone:[

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Cell Phone:

Parent Information:

Please check appropriate box and fill out information for that person:

MotherStepmotherGuardian

Last Name:

First Name:

Cell Phone:

Email:

Religion:

Employed by:

Occupation:

Business Address:

Work Phone:

Parent or Guardian (School correspondence mailed to the following) . Please print the information below:

Title:Please select1=Mr. & Mrs.2=Mrs.3=Mr.4=Ms.5=Miss

Last Name:

First Name:

Street Address:

City:

Apt:

State:

Zip::

Number to contact for school emergency communication via School Messenger ( snow day, power failure, etc.):

Do you want your contact information published in the QR Connects Directory?Please selectYesNo

Language spoken at home by student:

Mother’s maiden name:

Sibling/s Name:

Age: