Student Name:
Sex : Date of Birth :
Place of Birth:
Home Address:
Email Address:
Sibling(s) Enrolled::
Religion: Baptized: Yes   No
Local Public School System:
Local Public School Child Would Attend:
The following information is helpful when completing census data for grants and the National Catholic Education Association (NCEA) Data Bank. This information is not used in any way to determine admission and each label is adopted directly from then U.S. Census Bureau.
Race of the Student: Please check one of the following
Ethnicity of the Student: Please check one of the following
Family Information
Mother Father
Full Name
Maiden Name
Country of Birth
Home Address
Home Phone
Cell Phone
Preferred Email
Occupation
Employer
Work Phone
Religion
Parish/Church
Parents’ Marital Status: Single Married      Separated*      Divorced*
Please check all that apply: Mother Deceased Mother Remarried      Father Deceased      Father Remarried
* NOTE : Parents who are (or become) divorced, separated, unmarried, or who have any other special circumstances regarding the custody of their children must provide the school with a current court order or decree of custody for the student’s file. Any other specific instructions regarding release of the child or his/her records must be in writing and signed by the parent or parents with court-ordered legal custody. All parents/guardians with legal authority to make educational and religious decisions on behalf of the applicant must sign this form.
  Student lives with: Mother and Father      Mother Only      Father Only
      Legal Guardian (Please complete the information below):
Full Name:
Country of Birth:
Home Address:
Home Phone:
Cell Phone:
Preferred Email:
Occupation:
Employer:
Work Phone:
Religion:
Parish/Church:
Person responsible for Tuition/Fee Payments:
Emergency Contact Information
Please list the names of two adults who should be contacted in the event of an emergency if parents listed above cannot be reached
Contact #1:
Relation to Student: Email Address:
Home Address:
Home Phone Ext.
Contact #2:
Relation to Student: Email Address:
Home Address:
Home Phone Ext.
Student Background Information
Subject to the review and approval of the principal, students with special needs may be permitted to attend archdiocesan schools; however, parents must provide accurate and complete information regarding the applicant’s needs to assist schools in determining whether reasonable accommodations can be made.
Has your child received special services from a professional (e.g. counselor, speech therapist, special education teacher)?
No   Yes , Briefly describe the type of service, length of service, and if it discontinued, a reason for discontinuation:
Does your child need accommodations to be successful in school? No   Yes
If yes, please explain briefly (other forms will be required)
Does your child need any particular academic enrichment in order to successful in school? No   Yes ,   Please list :
Does your child have any diagnosed allergies? No   Yes
If yes, please list (other forms will be required)
Will your child require medication to be administered during the school day? No   Yes
If yes, please explain briefly (other forms will be required):
Medical Diagnosis: Please check all that apply:
No known medical conditions   Diagnosed Condition (specify)
Physical Disability
No existing physical disability Identified Disability (specify):
Learning Disorder:
No existing physical disability Identified Disability (specify):
Please provide copies of any completed diagnostic work, evaluations or specialized plans that have been developed for your child in the past, which may include psycho-educational evaluations, speech & language evaluations, an Individualized Educational Plan (IEP), a 504 plan, testing for Gifted and Talented Programs or any similar documents. Although archdiocesan Catholic Schools are not required to implement public schools’ special education plans, principals may determine the school is able provide reasonable accommodations in some circumstances.
Home Language Survey
Primary language(s) spoken in Does primary guardian
student's household: speak English? Yes No
  Does the student spend significant time with a non
Is the Student Bi-Lingual? No Yes English speaking caregiver? No Yes
NOTE: All of the Student Background Information and the Home Language Survey is requested for the sole purpose of determining whether the school can provide the applicant with an appropriate education and reasonable accommodations. It will not be considered in determining if he/she is otherwise qualified for admission. Submitting documentation of a disability in no way obligates the Catholic school to fulfill the student’s documented needs.
For Catholic Applicants Only
       Current Parish:       Pastor:
Sacramental Records:
Fully complete each section pertaining to Sacrament(s) the student has received.
Baptism: Date Church City State
Reconciliation: Date Church City State
First Eucharist: Date Church City State
Confirmation: Date Church City State
Transferring Student
Transferring Student : Is the student transferring from another school(s)?     Yes No
If YES, All Previous School(s) Attended:
Dates Attended : School Name : City : Phone Number : Grade Avg :
Dates Attended : School Name : City : Phone Number : Grade Avg :
Dates Attended : School Name : City : Phone Number : Grade Avg :
Dates Attended : School Name : City : Phone Number : Grade Avg :
Parent/Guardian Acknowledgment
I/We, the undersigned parent(s), understand and acknowledge that in the event that an Archdiocesan Catholic elementary school receives more qualified applicants than it has the capacity to accommodate, students shall be admitted in the following priority: Catholic students in the order in which they submit completed applications prior to the posted deadline; non-Catholic students in the order in which they submit completed applications prior to the posted deadline; all other students in the order in which they submit completed application after the posted deadline. I/We understand and acknowledge that all applicants shall follow all applicable policies and procedures regarding school-based entrance requirements, including, but not limited to, health examinations and immunizations, before admission may be finalized. Upon admission, all students in Catholic schools in the Archdiocese are to be immunized in accordance with the immunization requirements and the guidelines of the Archdiocese. Exemptions are provided only on a temporary basis to those with a physician-documented medical contraindication. I/We understand and acknowledge that the admission, instruction and retention of students with disabilities, students with special needs, and students who are English Language Learners cannot be guaranteed. Whether reasonable accommodations can be made for such students is determined on an individual basis and is in the sole discretion of the school’s chief administrator (principal) in consultation with the Catholic Schools Office. I/We understand and acknowledge the Roman Catholic religious nature of the school to which our child is applying. I/We will not publicly repudiate the teachings and traditions of the Roman Catholic Church, and I/we will respect and support the unique identity that the school derives from its Catholic faith. As the primary educator(s) of the applicant, I/We will not act in ways that contradict the Catholic nature of the school. I/we shall cooperate fully with the school and the applicant shall participate in all required school programming, including instruction in the Catholic faith and attendance at Mass. As the primary educator(s) of the applicant, we agree to act in ways that promote the best interests of the church and school and will comply with the policies of the Archdiocese of Washington and Saint Augustine Catholic School. I/We hereby confirm that the following documents, required to be considered for admission, including the non-refundable application fee of $375.00, accompany this application:
ALL STUDENT APPLICANTS
Non-Refundable Registration Fee of $375.00
Copy of Valid Age Birth Certificate
(Passport, Green Card, or Government IssuedIdentification)
Archdiocese of Washington Immunization Policy
Acknowledgment and All Attachments (Required for Admission)
Copy of Baptismal Certificate (Catholics only)
Allergy Agreement and Action Plan (If Applicable)
Copy of custody order, or other applicable court orders (If Applicable)
All relevant evaluations/assessments and previous special
education plans (If Applicable)
TRANSFER STUDENT APPLICANTS ONLY
All relevant evaluations/assessments and previous special
education plans (If Applicable)
All relevant evaluations/assessments and previous special education plans (If Applicable)
I/We hereby acknowledge that all the information contained in this application and its accompanying documents is accurate and truthful. I/We agree to pay all of applicant’s tuition and fees when due.
Names of Parents/Guardians:          Mother :           Father :
Sign and date : Sign and date
*All parents/guardians with legal authority to make educational and religious decisions on behalf of the applicant must sign this form.