Good Shepherd Catholic School

Student's Name

First Name Last Name

Student's Date of Birth

Date

Home Phone Number

Area Code Phone Number

Student's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Father's Name & Address

First Name Last Name

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Father's Email

example@example.com

Father's Phone Number - Home

Area Code Phone Number

Work

Area Code Phone Number

Cell

Area Code Phone Number

Mother's Name & Address (if different)

First Name Last Name

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mother's Email

example@example.com

Mother's Phone Number - Home

Area Code Phone Number

Work

Area Code Phone Number

Cell

Area Code Phone Number

Father's Place of Employment

Employment Address

Mother's Place of Employment

Business Name

Employment Address

Business Name & Address

Has any of the above information changed from last year?

For what grade is your child applying?

Please include any additional new information that you would like us to know about the applicant at this time.

Are you registered in a Catholic Church? If yes, which one?

My child was baptized at:

Is there another name and address to whom correspondence should be sent?

Student Emergency Information

Child's Physician

Physician's Phone Number

Date Last Seen

Allergies and any action to be taken in case of a reaction:

Medical Background (symptoms or history that the teacher should be aware of to protect your child's health).

Child's Dentist

Dentist name and phone number

Date Last Seen

Child's Therapist/Counselor

Therapist's Name and Phone Number

Date Last Seen

Please list two (2) nearby relatives or neighbors who will assume temporary care of your child(ren) if you cannot be reached.

Name

Phone Number

2.

Name

Phone Number

In case my child(ren) incur(s) an accident or illness or in any other situation that warrants an emergency response at school or during a school-related function, I expressly agree to give to Good Shepherd Catholic School personnel control to seek emergency medical care for my child(ren), including transportation to the emergency room if necessary. I understand that at school or during a school-related function it is Good Shepherd Catholic School personnel's sole discretion to make decisions about appropriate treatment necessary for my child(ren). I hereby authorize the health-care provider in charge to administer whatever treatment is necessary at my expense.

(Electronic) Signature of Parent/Guardian

I hereby give permission for

Physician

Physical mailing address:

to release medical immunization information to Good Shepherd Catholic School. I give Good Shepherd Catholic School permission to share any pertinent information regarding my child with the staff and faculty.

(Electronic) Signature of Parent/Guardian Date

Permission to Photograph:

I give my permission to for Good Shepherd Catholic School to photograph/videotape; during school related activities. These photos may be submitted to newspapers for publicity purposes and also may be posted on the G.S.C.S. website and social media outlets. Photos may also be placed in the Good Shepherd yearbook. I do not want my child to be photographed or videotaped during school related activities.

Transportation Permission: I give permission for the following person(s) to transport my child(ren):

Name Phone Number

Please fill this section out only if your child will be walking home at the end of the day on a regular basis. The days he or she will be regularly walking are:

Please list days of the week

Field Trips: Good Shepherd Catholic School regards the town of St. Johnsbury as a valuable academic and cultural resource. Teachers occasionally walk their classes to area places such as St. John's Church, The Father Lively Parish Center and playground, the Fairbanks Museum, the Athenaeum, the St. Johnsbury Academy, Catamount Arts, Canterbury Inn, the fire station or other nearby destinations. At times, a class may simply fo for a short walk as an exercise break.

I request that my child be allowed to take walking field trips in the town of St. Johnsbury. I do not want my child to participate in walking field trips.

Please verify that you are human *