Application for Admission to
St. Pio Catholic Regional School 2022-2023
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Family Address
Primary Family Address
Are you a registered parishioner of St. Richard Parish?
Yes
No
If NO, What is your current parish?
Family Last Name
Address
Primary E-mail
This will be the main e-mail address we will use to communicate with your family.
Primary Phone
This will be the main phone number we will use to communicate with your family.
Number of Children
1
2
3
4
5
Number of Children you will be registering today
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Father / Guardian
Name
Deceased
Yes
No
E-mail
Marital Status
Married
Divorced
Separated
Single
Widower
Religion
Cell Phone
Mother / Guardian
Name
Deceased
Yes
No
E-mail
Marital Status
Married
Divorced
Separated
Single
Widow
Religion
Cell Phone
Is there a custody agreement?
Yes
No
Children live with
Parents
Mother
Father
Guardian
Step-Parent
other:
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Child 1
Name
Gender
Male
Female
Date of Birth
School Grade
PreK 3 - 5 Full Days
PreK 3 - 5 Half Days
PreK 4 - 5 Full Days
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2022
Ethnicity
Hispanic
Non Hispanic
Race
American Indian/Native Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Two or More Race
Individual Education Program (IEP or 504)
No
Yes
Child 2
Name
Gender
Male
Female
Date of Birth
School Grade
PreK 3 - 5 Full Days
PreK 3 - 5 Half Days
PreK 4 - 5 Full Days
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2022
Ethnicity
Hispanic
Non Hispanic
Race
American Indian/Native Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Two or More Race
Individual Education Program (IEP or 504)
No
Yes
Child 3
Name
Gender
Male
Female
Date of Birth
School Grade
PreK 3 - 5 Full Days
PreK 3 - 5 Half Days
PreK 4 - 5 Full Days
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2022
Ethnicity
Hispanic
Non Hispanic
Race
American Indian/Native Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Two or More Race
Individual Education Program (IEP or 504)
No
Yes
Child 4
Name
Gender
Male
Female
Date of Birth
School Grade
PreK 3 - 5 Full Days
PreK 3 - 5 Half Days
PreK 4 - 5 Full Days
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2022
Ethnicity
Hispanic
Non Hispanic
Race
American Indian/Native Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Two or More Race
Individual Education Program (IEP or 504)
No
Yes
Child 5
Name
Gender
Male
Female
Date of Birth
School Grade
PreK 3 - 5 Full Days
PreK 3 - 5 Half Days
PreK 4 - 5 Full Days
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
School Grade in Fall 2022
Ethnicity
Hispanic
Non Hispanic
Race
American Indian/Native Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Two or More Race
Individual Education Program (IEP or 504)
No
Yes
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Immunizations
Are your child(ren)s immunizations up to date?
Yes
No
If no, have they received an exemption from your current school district?
Yes
No
Even if your child is exempt from immunizations, he/she may be excluded from school during an outbreak of the vaccine preventable disease.
If no, please explain
Emergency Contact
Emergency Contact Name 1
If we are unable to contact a parent in the event of an emergency, whom should we contact?
Relationship
Emergency Contact Phone 1
Emergency Contact Name 2
Relationship
Emergency Contact Phone 2
Total Amount
Once you have submitted this form you will then receive a call from the St. Pio School Office to complete the admission process for the 2022-2023 school year.
Verification
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SUBMIT FORM
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