Application for Admission
Application for Admission Date of Registration__________________ $100 School Year_________________ For Grade__________________
Non-refundable Registration Fee Cash:____________Check#__________
Please Print Child’s Name_____________________________________________________________Gender_______ Last First Middle Date of Birth_________________Place of Birth_________________Child’s S/S Number______________ Address____________________________________________City_______________State____Zip______ Home Telephone__________________ Father’s Cell_________________Mother’s Cell______________ Name of Father/Guardian________________________________________________________________ First M Last Occupation Religion Place of Employment____________________________________Father’s work phone_______________ Father’s email____________________ Name of Mother/Guardian_______________________________________________________________ First M Last Occupation Religion Place of Employment____________________________________Mother’s work phone______________ Mother’s email___________________ Step- Parent (if applicable)___________________________________________phone_______________ Student Lives with_____________________________________Relationship to child________________ Marital Status (please circle)
Married Single
Widowed Separated
Divorced Remarried
Baptism______________________________________________________________________________ Church City/State Date Holy Communion_______________________________________________________________________ Church City/State Date Confirmation__________________________________________________________________________ Church City/State Date If child is not Catholic, please state Religion____________________
Member of Immaculate Conception since____________________(date) If not, what Parish___________ Name/grade of other children at ICA_______________________________________________________ _____________________________________________________________________________________ Public School District:_______________________________Transportation: Bus, car rider (circle one) Name of Previous School_____________________________Address_____________________________
Emergency Contact Person_______________________________________________________________ Emergency Contact Person’s Telephone Number_____________________________________________
Please indicate any illness, handicap, allergy_________________________________________________ _____________________________________________________________________________________ Did your child receive any special services at their previous school?______Yes________ No________ If yes, what services were given….speech, reading, gifted, etc.___________________________________ _____________________________________________________________________________________ Did your child have an IEP (Individualized Education Plan)?__________Yes___________No____________ Note: In case of separated families, custody papers must be made available to the school.
By registering my child, I agree to abide by all of the rules and regulations outlined in the Immaculate Conception Academy handbook.
Parent Signature_________________________________________________Date____________ Parent Signature_________________________________________________Date____________
Please print Last Name___________________________________________
Please send completed application to: Immaculate Conception Academy 903 Chestnut Street Douglassville, PA 19518
Rev 1 (2015)
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Non-refundable Registration Fee Cash:____________Check#__________
Please Print Child’s Name_____________________________________________________________Gender_______ Last First Middle Date of Birth_________________Place of Birth_________________Child’s S/S Number______________ Address____________________________________________City_______________State____Zip______ Home Telephone__________________ Father’s Cell_________________Mother’s Cell______________ Name of Father/Guardian________________________________________________________________ First M Last Occupation Religion Place of Employment____________________________________Father’s work phone_______________ Father’s email____________________ Name of Mother/Guardian_______________________________________________________________ First M Last Occupation Religion Place of Employment____________________________________Mother’s work phone______________ Mother’s email___________________ Step- Parent (if applicable)___________________________________________phone_______________ Student Lives with_____________________________________Relationship to child________________ Marital Status (please circle)
Married Single
Widowed Separated
Divorced Remarried
Baptism______________________________________________________________________________ Church City/State Date Holy Communion_______________________________________________________________________ Church City/State Date Confirmation__________________________________________________________________________ Church City/State Date If child is not Catholic, please state Religion____________________
Member of Immaculate Conception since____________________(date) If not, what Parish___________ Name/grade of other children at ICA_______________________________________________________ _____________________________________________________________________________________ Public School District:_______________________________Transportation: Bus, car rider (circle one) Name of Previous School_____________________________Address_____________________________
Emergency Contact Person_______________________________________________________________ Emergency Contact Person’s Telephone Number_____________________________________________
Please indicate any illness, handicap, allergy_________________________________________________ _____________________________________________________________________________________ Did your child receive any special services at their previous school?______Yes________ No________ If yes, what services were given….speech, reading, gifted, etc.___________________________________ _____________________________________________________________________________________ Did your child have an IEP (Individualized Education Plan)?__________Yes___________No____________ Note: In case of separated families, custody papers must be made available to the school.
By registering my child, I agree to abide by all of the rules and regulations outlined in the Immaculate Conception Academy handbook.
Parent Signature_________________________________________________Date____________ Parent Signature_________________________________________________Date____________
Please print Last Name___________________________________________
Please send completed application to: Immaculate Conception Academy 903 Chestnut Street Douglassville, PA 19518
Rev 1 (2015)
Page 2 of 2
