Registration Form – St. Vivian Catholic School

Student Information

I am Enrolling *

Do you have any siblings currently enrolled? *

Please list name(s) of enrolled sibling(s)

Last Name of Student *

First Name of Student *

Middle Initial

Nickname

Date of Birth *//

Upload Birth Certificate

Gender *

Religion *

Parish *

Upload Baptismal Certificate

Upload Certificate of First Reconciliation

Upload Certificate of First Communion

Upload Certificate of Confirmation

Applying for Entry into Grade *

Public School District *

Public School Building (Name) *

Are you transferring from or currently enrolled in another school? *

Previous School Attended

Previous School Phone

Previous School Fax

Previous School Address

Address Line 1

Address Line 2

City

State

Zip Code

Upload Previous Report Card(s)

Do you want to apply for bus service? *

Access the scholarship form here: https://online.factsmgt.com/signin/3XF84

Will you be applying for an Ohio EdChoice Scholarship? *

Access the scholarship form here: https://online.factsmgt.com/signin/3XF84

Which Program?

Access the scholarship form here:

https://online.factsmgt.com/signin/3XF84

Income eligibility guidelines:

http://education.ohio.gov/getattachment/Topics/Other-Resources/Scholarships/EdChoice-Scholarship-Program/FederalPovertyGuidelines.pdf

Family Information

Student Resides With *

Upload Court/Custody Documents

Primary Guardian Name *

First

Last

Primary Guardian SSN *

If you do not have a SSN, please enter all 0's. You will be contacted by our Business Office to gather supporting documents. Not providing your SSN will delay your child's acceptance or push them to a waiting list.

Primary Guardian Relationship *

Primary Phone *

Primary Email *

Primary Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Occupation & Place of Employment *

Primary Work Phone

Secondary Guardian Name

First

Last

Secondary Guardian SSN

Secondary Guardian Relationship

Secondary Phone

Secondary Email

Secondary Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Occupation & Place of Employment

Secondary Work Phone

Release/Emergency Contacts

Emergency Contact #1 *

First

Last

Phone *

Email *

Relation to Student *

Emergency Contact #2 *

First

Last

Phone *

Email *

Relation to Student *

Medical Providers

Physician Name *

Physician Phone *

Dentist Name *

Dentist Phone *

Insurance Provider

Policy #

Demographics

Hispanic? *

Ethnicity *

Primary Language *

Secondary Language

Academics

Has the student had any of the following academic testing/evaluations?

Upload Evaluation Documentation

Has the student been enrolled in any special programs in or out of school?

Has the student *

had/has ISP/IEP
Been Retained
Prescribed Medication
None of the above

If you chose one or more options, please specify the area/give more detail below