Register your child at Mother of Divine Grace for 2018-2019 today!
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Registration Form 2018-2019
Mother of Divine Grace Catholic School
2612 East Monmouth Street
Philadelphia PA 19134
REGISTRATION FORM
ACADEMIC YEAR 2018-2019
STUDENT INFORMATION
PLEASE PRINT ALL INFORMATION
Name_______________________________________________________________________
Last First Middle
Grade child will be enrolled in for 2018-2019________________________________________
Social Security________________________________________________________________
Date of Birth__________________________________________________________________
Gender___________________ Place of Birth_________________________________
City State
Country of Citizenship___________________________________________________________
Language spoken at home_______________________________________________________
Address______________________________________________________________________
City____________________________________ State______________ Zip Code___________
Home Phone__________________________________________________________________
Email Address__________________________________________________________________
Religion___________________________ Registered Parish___________________________
School admitted from___________________________________________________________
FAMILY INFORMATION
First and Last Name of Father_____________________________________________________
Country of Citizenship______________________ Check if deceased___________
Occupation_________________________________________Religion____________________
First, Maiden and Last Name of Mother______________________________________________
Country of Citizenship _______________________ Check if deceased____________
Occupation_________________________________________ Religion___________________
Please list the name and address of the person or people who are financially responsible for this child’s school tuition and fees.
Name ________________________________________________________________________
Address_______________________________________________________________________
City, State, Zip Code_____________________________________________________________
Phone Number_________________________________________________________________
Child lives with: ________Mother and Father ________Mother ________Father
________Mother/Stepfather _________Father/Stepmother ________Grandparents
If other, please explain___________________________________________________________
Parental rights (in case of separation or divorce)_______________________________________
Attach copy of court order.
SACRAMENTAL RECORD
Date Parish City State
Baptism ________________________________________________________________
Penance ________________________________________________________________
Holy Eucharist________________________________________________________________
Confirmation ________________________________________________________________
HEALTH RECORD
Is there any information that the staff of Mother of Divine Catholic Grace School should know about your child’s health, home situation, past education problems, etc. that may have an effect on his or her learning? Please list and explain below:
*Allergies?
*Previous educational testing?
*Psychological Services?
*Eyeglasses, vision loss?
*Speech/Language Therapy?
*Previous Special Education Groups?
*Medications (examples: Ritalin, Insulin)?
*History of hearing difficulties, tubes in ears, frequent ear infection?
*Any thing you would like to tell the staff about your child and his/her school experiences?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature of Registering Parent____________________________________________________
REGISTRAR’S RECORDS
Birth Certificate____________________ Baptismal Certificate__________________
Immunization Records________________ Social Security Card___________________
Copy of Court Order__________________ Remain in school for lunch______________
Letter from Pastor if Non Parishioner __________ Remaining for C.A.R.E.S. ______________
Registration Fee Paid ________________________________
Check Number___________________ Money Order Number____________________
Registrar___________________________________________________________________
Date_______________________________________________________________________