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Family Information Form 2022-2023

Please complete and submit the form below.

All fields marked with * are required

Family Name*

Answer Required

STUDENT INFORMATION - KINDERGARTEN - GRADE 8

STUDENT 1

Student Name:

Answer Required

Grade:

Answer Required

Date of Birth

Answer Required

STUDENT 2

Student Name:

Answer Required

Grade:

Answer Required

Date of Birth

Answer Required

STUDENT 3

Student Name:

Answer Required

Grade:

Answer Required

Date of Birth

Answer Required

STUDENT 4

Student Name:

Answer Required

Grade:

Answer Required

Date of Birth

Answer Required

STUDENT INFORMATION - PRESCHOOL

STUDENT 1

Student Name:

Answer Required

Date of Birth

Answer Required

STUDENT 2

Student Name

Answer Required

Students turning three after September1st will be required to start the year in the 11:15 am class. Adjustments can be made with teacher approval after November 1st.

CONTACT INFORMATION

Mother/Guardian

Mother's Full Name*

Title/First/Last

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Cell Phone*

Number Required

Home Phone

Number Required

Work Phone

Number Required

Primary Email (used for ALL communication): *

Answer Required

Occupation/Title:

Answer Required

Name of Employer

Answer Required

Father/Guardian

Father's Full Name*

Title/First/Last

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Cell Phone*

Number Required

Home Phone

Number Required

Work Phone

Number Required

Primary Email (used for ALL communication): *

Answer Required

Occupation/Title:

Answer Required

Name of Employer

Answer Required

If you answered OTHER for the question above, please explain...

Answer Required

If divorced/separated, are there any custody/visitation restrictions? If YES please specify

Documentation must be provided

Answer Required

OTHER

If you answered YES for the question above, please list all the people: NAME, RELATIONSHIP & YEARS ATTENDED

Answer Required

CURRENT FAMILIES

BUS DISMISSAL for Trumbull residents ONLY available to kindergarten to grade 8 students.

MEDIA RELEASE

SIGNATURES

I/We hereby certify that all of the information provided is accurate and that my child(ren) and I/we agree to abide by all of the policies and procedures in the St. Catherine of Siena School Handbook, including the tuition policy and the Acceptable Use Policy for Digital Media as determined by the Diocese of Bridgeport.

Signature of Parent or Guardian 1:*

Answer Required

Date*

Answer Required

Signature of Parent or Guardian 2:*

Answer Required

Date*

Answer Required

EMERGENCY CONTACT INFORMATION (other than parents or guardian)

1: Name:*

Answer Required

Cell Phone:*

Number Required

Home/Work Phone:

Number Required

Relationship:*

Answer Required

2: Name:*

Answer Required

Cell Phone:*

Number Required

Home/Work Phone:

Number Required

Relationship:*

Answer Required

MEDICAL INFORMATION (that you would like to share with staff)

Student #1 Name:

Answer Required

Grade:

Answer Required

Medical Conditions:

Answer Required

Allergies:

Answer Required

Student #2 Name:

Answer Required

Grade:

Answer Required

Medical Conditions:

Answer Required

Allergies:

Answer Required

Student #3 Name:

Answer Required

Grade:

Answer Required

Medical Conditions:

Answer Required

Allergies:

Answer Required

Student #4 Name:

Answer Required

Grade:

Answer Required

Medical Conditions:

Answer Required

Allergies:

Answer Required

PHYSICIAN / DENTIST / INSURANCE INFORMATION

Physician Name: *

Answer Required

Phone Number:

Number Required

Dentist Name: *

Answer Required

Phone Number:

Number Required

Name of Insurance Company:*

Answer Required

ID#

Answer Required

Authorization for a Life-threatening Situation or Medical Emergency

In the event of wh at the school deems to be a medical emergency, I understand the school will call 911 and request an ambulance or police transport to a hospital for emergency treatment. I further un derstand the school will make every effort to contact me directly before transport.

Parent/Guardian Signature:*

Answer Required

Date:*

Answer Required

Medical Information Consent

Medical information may be shared confidentially with school staff and emergency responders as needed. I give permission for the release and exchange of informa tion of any health issues between the school nurse and health care providers for confident ial use in meeting my child's health and education needs in school.

Parent/Guardian Signature:

Answer Required

Date:

Answer Required

I hereby certify that all of the above information is accurate, by SUBMITTING the form.

190 Shelton Rd Trumbull, CT, 06611 - (203) 375 1947 - admissions @scsstrumbull.org - w ww.stcatherinesienatrumbull.org

Confirmation Email

Confirmation Email *

Email Required