Application for International Admission
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Application Form for INTERNATIONAL ADMISSION 2016/2017
Diocese of Syracuse - Catholic Schools
---Please Print---
Applying for admission to:Bishop Grimes Jr/Sr High School (7-12)Grade Entering: ______Male Female
Student Name ______DOB______Place of Birth______
Last First Middle
Address______City______State______Zip______
Religion: Catholic Non-Catholic Student’s Parish______
Student lives with Both Parents Mother Father Other (please specify) ______
Custody: This school assumes that both parents have full parental and residential custody. If this is not the case, it is the responsibility of the parents to provide the school with that portion of the divorce decree or separation agreement that articulates parental and residential custody. Should any changes occur during the year, please inform the school.
Please check here if the school will be receiving a custody document.
Parental Information:
Note: Both parents have a right to school information regarding the student unless one parent presents a legal document that does not permit this.
Mother/Father/Guardian Name: ____________Religion:______
Address______City______State______Zip______
Home Phone (______) ______Work Phone (______) ______Cell Phone (______) ______
Occupation______Employer Name ______
Email: ______
Host Family/Guardian Name:______Religion:______
Address______City______State______Zip______
Home Phone (______) ______Work Phone (______) ______Cell Phone (______) ______
Occupation______Employer Name ______
Email: ______
If there are additional contacts please notify the school.
If Student is Catholic, please complete the following:
BaptismChurch: ______Date: ______
First PenanceChurch: ______Date: ______
First EucharistChurch: ______Date: ______
ConfirmationChurch: ______Date: ______
HANDBOOK:
I understand that the Student Handbook contains the official policies and procedures of the school and Iagree to be governed by the 2016-2017 Bishop Grimes Handbook which can be found on the school website.
Student Signature ______Date: ______
Host/Guardian Signature ______Date: ______
Release for Use of Student Photos and Videos for School Media Purposes
Student Signature ______Date: ______
Host/Guardian Signature ______Date: ______
Transportation
Public School District in which the student resides ______For students residing within the Syracuse City School District, Bishop Grimes will submit transportation requests on the students behalf. For Students outside of the Syracuse City School District, parents need to complete transportation forms by April 1st, 2016. Forms must be completed to receive busing services.
Ethnic background of student Hispanic Non-Hispanic
Race American Indian Native Alaskan Asian Black Native Hawaiian/Pacific Islander White 2 or more races
This information is used to complete the New York State Basic Educational Data Systems report that all public and non-public schools are required to submit.
Current School ______Grade: ______
Reason for Leaving ______
Academic Information:
Unofficial copies of transcripts and reports have been requested or are attached for admission purposes. Acceptances are not final until
records have been reviewed by the principal.
Does the student have a Behavioral Intervention Plan? Yes No If yes, what are the terms of that plan? Please provide the school
with a copy of that plan. Please specify below:
Does the student require any particular accommodations to facilitate his or her participation in the educational program offered by the school
other than what has been indicated in the question above? Yes No. If so, what are those accommodations? Please specify below:
Has the student ever been tested for learning problems? Yes No
Has testing for learning problems ever been suggested? Yes No
Does the student have an IEP or IESP? Yes No
Does the student have a 504 Accommodation Plan? Yes No
I understand that the school must be informed of any physical, mental or emotional limitation known by the parents that could
affect appropriate placement. Providing inaccurate or incomplete information during the application process will result in non-acceptance or
dismissal from the school. Classroom placement is determined by the school. Initial Please:______
Is the student currently taking medications? Yes No If yes, please specify: ______
Does the medication need to be administered during the school day? Yes No. If yes, when? ______
Emergency Contacts (Mandatory) Other than Parents
Name ______Relationship ______
Home Phone (______) ______Work Phone (______) ______Cell Phone (______) ______
Name ______Relationship ______
Home Phone (______) ______Work Phone (______) ______Cell Phone (______) ______
Name ______Relationship ______
Home Phone (______) ______Work Phone (______) ______Cell Phone (______) ______
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Financial Information
2016-2017 TUITION RATES: GRADES 7-12: $9,500
Additional Fees:
Non-refundable deposit prior to skype interview: $250.00
New Student Fee: $25.00 per student. Non-refundable
I-20 Fee: $50.00
School Fees: $250.00 per student (Books: $135, Academic Fee: $40, Technology Fee: $75)
2016-2017 TUITION PAYMENT POLICY:
1. A student may not begin in September if there is past due tuition owed at Bishop Grimes or another Syracuse Diocesan Catholic school.
2. A Smart Tuition payment plan must be in place in order for a student to start the new school year.
3. The privilege of participating in graduation ceremonies and school activities may be suspended if tuition is not paid in full.
4. In the event that tuition is left unpaid, the school will refer your tuition account to our collection attorney and you will be
responsible for all collection related fees.
I have read the tuition and payment policy of the school. I am responsible to make tuition and fee payments for the student
whose name is on this application, less any financial aid granted for the 2016-2017 school year.
Person Responsible for Payment of Tuition – It is agreed that tuition will be paid as indicated on SMART Tuition Enrollment form and form must complete in order to register your child. (Please Print):
Name: ______
Address______City______State____Zip______
***REQUIRED SIGNATURE: ______Date: ______
Please provide your Social Security Number: ______
Complete the section below only if someone other than a parent will be responsible for the student’s tuition.
Name(s) of the person(s) responsible for tuition if other than a parent:
Name______Home Phone (______) ______
Address______City______State____Zip______
Employer ______Work Phone (______) ______Cell Phone (______) ______
I have read the tuition and payment policy of the school. I am responsible to make tuition payments for the student whose name is on this
application, less any financial aid granted, for the 2016-2017 school year according to the option selected above.
______-______-______
Signature of Person Responsible for Tuition Other than Parent Date Social Security #
FOR OFFICE USE ONLY: Tuition Deposit Received: ______Check #/Cash: ______Date: ______
Tuition Charge for 2016-2017 : ______Family ID#______