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Enrollment

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  Family Data - Mother
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Maiden Name Please enter valid data.
  
  Mother's Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Occupation Please enter valid data.
  
  Employer Please enter valid data.
  
  Business Phone Please enter valid data.
  
  Religion Please enter valid data.
  
  Registered Parish Please enter valid data.
  
  Church Envelope Number: Please enter valid data.
  
  Mother is Catholic School Alumni? REQUIRED Yes No Please fill out this field.
  
  Father's Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Occupation Please enter valid data.
  
  Employer Please enter valid data.
  
  Business Phone Please enter valid data.
  
  Religion Please enter valid data.
  
  Registered Parish Please enter valid data.
  
  Church Envelope Number: Please enter valid data.
  
  Father is Catholic School Alumni? REQUIRED Yes No Please fill out this field.
  
  Family Data - General
  
  Student Resides With Both Parents Mother Only Father Only Join Custody
  
  Other Please enter valid data.
  
  Parents/Guardians Marital Status Married Separated Divorced Widowed Single Parent
  
  Other Please enter valid data.
  
  Please list any talents or interests you will be willing to share with the school
  
  Second Address
  
  If mail is to be sent to a second address, please complete:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Second Address Recipient Relationship Please enter valid data.
  
  Family Data - Children Under 18 REQUIRED Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Gender Male Female
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Gender Male Female
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Gender Male Female
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Gender Male Female
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Student Data REQUIRED Please fill out this field.
  
  Student 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Entering Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Gender Male Female
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Birth Certificate Number REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Student's Age as of September 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Public School District of Residence (Taxes Paid To) Please enter valid data.
  
  Public School Building this student would attend, if not enrolled in Please enter valid data.
  
  Current School/Preschool Please enter valid data.
  
  Address of Current School/Preschool
  
  Student's Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Registered Parish/Church REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Ethnicity REQUIRED Hispanic African-American Asian Native American Caucasian Multi-Racial Pacific Island Please fill out this field.
  
  If other: Please enter valid data.
  
  Guardianship (if applicable)
  
  Student's legal guardian (if other than parent) Please enter valid data.
  
  Relationship to the Student Please enter valid data.
  
  Date of Baptism REQUIRED Please fill out this field. Please enter a date.
  
  Church, City, State where Baptized Please enter valid data.
  
  Date of Reconciliation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Reconciliation Please enter valid data.
  
  Date of First Holy Eucharist REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Holy Eucharist Please enter valid data.
  
  Date of Confirmation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where Confirmed Please enter valid data.
  
  Had a psychological evaluation? REQUIRED Yes No Please fill out this field.
  
  If yes, please indicate school year, grade and formal report
  
  Been diagnosed with any of the following:
  (Please submit formal written diagnosis report at time of enrollment meeting)
  LD (Learning Disability) ADD (Attention Deficit Disorder) ADHD (Attention Deficit Hyperactive Disorder) ASD (Autism Spectrum Disorder) ODD (Oppositional Defiant Disorder) Other
  
  Does your child take medication associated with this diagnosis? Not Applicable Yes No
  
  Been diagnosed with a medical condition that the school should be aware of? No Yes
  
  Received any of the following services: Counseling Emotional Support Gifted Support Remedial Math Remedial Reading Speech/Language Project Dart Learning Support Other
  
  Other services student has received: Please enter valid data.
  
  Had an IEP? Please enter valid data.
  
  Repeated a grade? Please enter valid data.
  
  Received a suspension from school? Please enter valid data.
  
  Been asked to transfer? Please enter valid data.
  
  Been expelled from school? Please enter valid data.
  
  Agreement REQUIRED By clicking this box I approve the information to be shared with Butler Catholic School, and recognize this as an electronic personal signature. Please fill out this field.
  
  Student 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Entering Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Gender Male Female
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Birth Certificate Number REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Student's Age as of September 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Public School District of Residence (Taxes Paid To) Please enter valid data.
  
  Public School Building this student would attend, if not enrolled in Please enter valid data.
  
  Current School/Preschool Please enter valid data.
  
  Address of Current School/Preschool
  
  Student's Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Registered Parish/Church REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Ethnicity REQUIRED Hispanic African-American Asian Native American Caucasian Multi-Racial Pacific Island Please fill out this field.
  
  If other: Please enter valid data.
  
  Guardianship (if applicable)
  
  Student's legal guardian (if other than parent) Please enter valid data.
  
  Relationship to the Student Please enter valid data.
  
  Date of Baptism REQUIRED Please fill out this field. Please enter a date.
  
  Church, City, State where Baptized Please enter valid data.
  
  Date of Reconciliation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Reconciliation Please enter valid data.
  
  Date of First Holy Eucharist REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Holy Eucharist Please enter valid data.
  
  Date of Confirmation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where Confirmed Please enter valid data.
  
  Had a psychological evaluation? REQUIRED Yes No Please fill out this field.
  
  If yes, please indicate school year, grade and formal report
  
  Been diagnosed with any of the following:
  (Please submit formal written diagnosis report at time of enrollment meeting)
  LD (Learning Disability) ADD (Attention Deficit Disorder) ADHD (Attention Deficit Hyperactive Disorder) ASD (Autism Spectrum Disorder) ODD (Oppositional Defiant Disorder) Other
  
  Does your child take medication associated with this diagnosis? Not Applicable Yes No
  
  Been diagnosed with a medical condition that the school should be aware of? No Yes
  
  Received any of the following services: Counseling Emotional Support Gifted Support Remedial Math Remedial Reading Speech/Language Project Dart Learning Support Other
  
  Other services student has received: Please enter valid data.
  
  Had an IEP? Please enter valid data.
  
  Repeated a grade? Please enter valid data.
  
  Received a suspension from school? Please enter valid data.
  
  Been asked to transfer? Please enter valid data.
  
  Been expelled from school? Please enter valid data.
  
  Agreement REQUIRED By clicking this box I approve the information to be shared with Butler Catholic School, and recognize this as an electronic personal signature. Please fill out this field.
  
  Student 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Entering Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Gender Male Female
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Birth Certificate Number REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Student's Age as of September 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Public School District of Residence (Taxes Paid To) Please enter valid data.
  
  Public School Building this student would attend, if not enrolled in Please enter valid data.
  
  Current School/Preschool Please enter valid data.
  
  Address of Current School/Preschool
  
  Student's Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Registered Parish/Church REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Ethnicity REQUIRED Hispanic African-American Asian Native American Caucasian Multi-Racial Pacific Island Please fill out this field.
  
  If other: Please enter valid data.
  
  Guardianship (if applicable)
  
  Student's legal guardian (if other than parent) Please enter valid data.
  
  Relationship to the Student Please enter valid data.
  
  Date of Baptism REQUIRED Please fill out this field. Please enter a date.
  
  Church, City, State where Baptized Please enter valid data.
  
  Date of Reconciliation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Reconciliation Please enter valid data.
  
  Date of First Holy Eucharist REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Holy Eucharist Please enter valid data.
  
  Date of Confirmation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where Confirmed Please enter valid data.
  
  Had a psychological evaluation? REQUIRED Yes No Please fill out this field.
  
  If yes, please indicate school year, grade and formal report
  
  Been diagnosed with any of the following:
  (Please submit formal written diagnosis report at time of enrollment meeting)
  LD (Learning Disability) ADD (Attention Deficit Disorder) ADHD (Attention Deficit Hyperactive Disorder) ASD (Autism Spectrum Disorder) ODD (Oppositional Defiant Disorder) Other
  
  Does your child take medication associated with this diagnosis? Not Applicable Yes No
  
  Been diagnosed with a medical condition that the school should be aware of? No Yes
  
  Received any of the following services: Counseling Emotional Support Gifted Support Remedial Math Remedial Reading Speech/Language Project Dart Learning Support Other
  
  Other services student has received: Please enter valid data.
  
  Had an IEP? Please enter valid data.
  
  Repeated a grade? Please enter valid data.
  
  Received a suspension from school? Please enter valid data.
  
  Been asked to transfer? Please enter valid data.
  
  Been expelled from school? Please enter valid data.
  
  Agreement REQUIRED By clicking this box I approve the information to be shared with Butler Catholic School, and recognize this as an electronic personal signature. Please fill out this field.
  
  Student 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Entering Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Gender Male Female
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Birth Certificate Number REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Student's Age as of September 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Public School District of Residence (Taxes Paid To) Please enter valid data.
  
  Public School Building this student would attend, if not enrolled in Please enter valid data.
  
  Current School/Preschool Please enter valid data.
  
  Address of Current School/Preschool
  
  Student's Religion REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Registered Parish/Church REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Ethnicity REQUIRED Hispanic African-American Asian Native American Caucasian Multi-Racial Pacific Island Please fill out this field.
  
  If other: Please enter valid data.
  
  Guardianship (if applicable)
  
  Student's legal guardian (if other than parent) Please enter valid data.
  
  Relationship to the Student Please enter valid data.
  
  Date of Baptism REQUIRED Please fill out this field. Please enter a date.
  
  Church, City, State where Baptized Please enter valid data.
  
  Date of Reconciliation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Reconciliation Please enter valid data.
  
  Date of First Holy Eucharist REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where received First Holy Eucharist Please enter valid data.
  
  Date of Confirmation REQUIRED Please fill out this field. Please enter a date.
  
  Church, city, and state where Confirmed Please enter valid data.
  
  Had a psychological evaluation? REQUIRED Yes No Please fill out this field.
  
  If yes, please indicate school year, grade and formal report
  
  Been diagnosed with any of the following:
  (Please submit formal written diagnosis report at time of enrollment meeting)
  LD (Learning Disability) ADD (Attention Deficit Disorder) ADHD (Attention Deficit Hyperactive Disorder) ASD (Autism Spectrum Disorder) ODD (Oppositional Defiant Disorder) Other
  
  Does your child take medication associated with this diagnosis? Not Applicable Yes No
  
  Been diagnosed with a medical condition that the school should be aware of? No Yes
  
  Received any of the following services: Counseling Emotional Support Gifted Support Remedial Math Remedial Reading Speech/Language Project Dart Learning Support Other
  
  Other services student has received: Please enter valid data.
  
  Had an IEP? Please enter valid data.
  
  Repeated a grade? Please enter valid data.
  
  Received a suspension from school? Please enter valid data.
  
  Been asked to transfer? Please enter valid data.
  
  Been expelled from school? Please enter valid data.
  
  Agreement REQUIRED By clicking this box I approve the information to be shared with Butler Catholic School, and recognize this as an electronic personal signature. Please fill out this field.
  
  Submit
  
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Enrollment

Guardianship (if applicable)

Guardianship (if applicable)

Guardianship (if applicable)

Guardianship (if applicable)