Holy Rosary High School

APPLICATION FOR ADMISSION

Date______

Expected Start Date ______

STUDENT INFORMATION

Name: Last______First______Middle ______

Name that the applicant prefers to be called in school: ______Grade Applying For: ______

Date of Birth: ______M or F SSN: ______

(Circle)

Religion ______Church/Parish/Location ______

First Communion Date______Church/Location ______

Please check one: _____Am. Indian/Alaskan Native _____Black/African American _____ Asian

_____ White/Caucasian _____ Hispanic/Latino _____ Native Hawaiian/Pacific Islander _____Multi-Racial

Mailing Address ______Home Phone ______

______Place of Birth ______

PRIMARY PARENT/GUARDIAN

(Mr. and Mrs.) (Mr.) (Ms.)______

Address: Street______City ______State______Zip______

Mother’s Phone: Home ( ) ______Cell ( )______Work ( )______

Father’s Phone: Home ( ) ______Cell ( )______Work ) )______

E-Mail______

Mother Employer______Occupation______

Father Employer______Occupation______

SECONDARY PARENT/ GUARDIAN (not living with student)

(Mr. and Mrs.) (Mr..) (Ms.)______

Address: Street______City______State______Zip______

Mother’s Phone: Home ( )______Cell ( )______Work ( )______

Father’s Phone: Home ( )______Cell ( )______Work ( )______

E-Mail______

Mother Employer______Occupation______

Father Employer______Occupation______

EDUCATIONAL BACKGROUND OF PARENT(S) OR GUARDIAN(S):

______

Father

______

Mother

Resides with (check all that apply) _____Mother _____Father _____Step-Mother _____Step-Father _____Guardian

Custody (check all that apply) ______Natural Parents _____Father ______Mother ______Guardian ______Other

Financially Responsible Party ______

Street (if different from above) ______City______State ______Zip ______

Siblings Who Attend Holy Rosary______

REFERENCES:

Name of person who referred you to HolyRosaryHigh School: ______

Name of person who knows the whole family and can serve as a reference: ______

______

Street City, State Zip

______

Home Phone Cell Phone

Has the Applicant ever applied to Holy Rosary High School before: Y or N (Circle)

If so, when? ______

Please list relatives who are HolyRosaryAcademy alumni or currently enrolled students:

NameRelationship:Dates of Attendance

______

MEDICAL INFORMATION:

GENERAL HEALTH: ______GOOD ______FAIR ______POOR

Please list any special health issues/concerns (including allergies):______

______

DOES YOUR CHILD HAVE A HISTORY OF ANY OF THE FOLLOWING?

___Constant Colds___Asthma___Respiratory Infections

___Headaches___Migraines___Dizziness and/or Fainting Spells

___Bed Wetting___Bladder Problems___Accidents (i.e. broken bones)

___Abdominal Pains___Seizures___Ear Infections

SURGERY: ___Tonsils___Adenoids___other______

HAS YOUR CHILD BEEN IDENTIFIED AS HAVING ADHD / ADD? Y or N (Circle)

IF SO, WHEN? ______

IS YOUR CHILD CURRENTLY ON ANY MEDICATION? ______IF SO, PLEASE LIST:

TYPE: ______DOSAGE: ______TIMES PER DAY: ______

SUPERVISINGPHYSICIAN: ______PHONE: ______

IN THE FAMILY, YOUR CHILD IS #______OF #______CHILDREN.

List Siblings and Ages: ______

HAS YOUR CHILD EVER RECEIVED COUNSELING? ______

Please Describe Type And Problems Addressed: (Please use additional sheets if necessary.)

CURRENT DEVELOPMENT:

DATE OF LAST PHYSICAL EXAM: ______By whom? ______

Describe any Physical Problems: ______

DATE OF LAST VISION EXAM: ______By whom? ______

Describe Any Vision Problems______

DATE OF LAST HEARING EXAM: ______By whom? ______

Describe Any Hearing Problems: ______

HAS YOUR CHILD HAD A NEUROLOGICAL EXAM? ______If so, when? ______

I (we) authorize and consent to my child, a minor, receiving any x-ray examination, medical, or surgical diagnosis or treatment supervision upon the advice of a licensed physician. It is understood that reasonable efforts shall be made to contact the undersigned prior to rendering treatment, but that treatment will not be withheld if the undersigned cannot be reached.

Signature of Mother/Guardian ______Date ______

Signature of Father/Guardian ______Date ______

EMERGENCY CONTACT INFORMATION (other than parent/guardian)

Name ______Relation ______Home ______Cell ______

Name ______Relation ______Home ______Cell______

Name ______Relation ______Home ______Cell ______

EMERGENCY STUDENT RELEASE: In the event of an emergency in which it is necessary for my child to be released early from HR, I hereby authorize HR to permit him/her to exercise the option(s) below. With the exception of Option #1, I understand that the responsibility of the school for the safety of my child terminates immediately upon his/her exercising this option. I hereby absolve HR and/or its administrators from any liability or claims, of any nature whatsoever, for anything arising out of, or resulting directly or indirectly from, his/her exercise of such option.

_____ Option 1 – Permit my child to take the HR bus at the time of dismissal

_____ Option 2 – Permit my child to leave campus with those persons listed under Dismissal Student

Release Section

_____ Option 3 – Permit my child to leave school with his/her carpool. Student carpool names and number

______

_____ Option 4 – Permit my child to leave campus using his/her own vehicle, if applicable

_____ Option 5 – Permit my child to leave campus only with his parents/guardian.

_____ Option 6 – Permit my child to leave campus with another student. Name ______

DISMISSAL STUDENT RELEASE: These are the persons who have permission to pick up my child (ren):

Name______Phone ______Relationship ______

TESTING HISTORY:

Date of most recent educational testing:______EXAMINER: ______

Date(s) Of Previous Testing: ______

Date of most recent psychological testing:______EXAMINER: ______

Date(s) Of Previous Psychological Testing: ______

Date of most recent language evaluation:______EXAMINER______

Date of recent occupational therapy evaluation: ______EXAMINER:______

Is your child currently receiving speech therapy?______From whom: ______

Pleasedescribe: ______

Is your child currently being tutored? ______By Whom? ______

How often?______Subject Areas: ______

SCHOOL HISTORY:

Current school: ______

______

Street City, State Zip Code

______

Phone Fax

Principal: ______

May we contact your current school for additional information? ______

PREVIOUS SCHOOL(S): (Attach an additional sheet if necessary)

______

Name of SchoolName of School

______

StreetStreet

______

City, State, Zip CodeCity, State, Zip Code

______

PhonePhone

______

Grades Attended/Dates of EnrollmentGrades Attended/Dates of Enrollment

Maternal Grandparents

(Mr. and Mrs.) (Mr.) (Ms.)______

Mailing Address: Street______City ______State ______Zip ______

Paternal Grandparents

(Mr. and Mrs.) (Mr.) (Ms.)______

Mailing Address: Street______City ______State ______Zip ______

Additional Grandparents:

(Mr. and Mrs.) (Mr.) (Ms.)______

Mailing Address: Street______City______State______Zip______

PARENT(S) QUESTIONNAIRE

To be completed by parent or legal guardian.

What do you perceive to be your son/daughter’s strengths, abilities, and talents?

What do you perceive to be your son/daughter’s areas of greatest need(s)? (Check all that apply)

____Academic

____Reading____Social Studies____Math____Science

____Social

____Peer Relationships ____Familial Relationships ____Teacher/Authority

____Behavioral

____Impulsivity____Knowing Limits____Response to Authority

____Following Rules

____Attention to Task

What do you consider to be your son/daughter’s primary difficulties in school?

Has your son/daughter displayed any behavior problems in school or at home? Explain.

Has your son/daughter been identified by a public school system as being learning disabled?

_____Behavioral Disability _____Emotional Disability

_____Asperger’s Syndrome _____Autism

_____Other______

Explain ______

Please describe any concerns you may have about your child’s social, emotional, or behavioral functioning.

Is your son/daughter presently motivated to learn?

Does your son/daughter initiate reading on his/her own? ______

If so, what are his/her reading interests?

Has your son/daughter ever repeated a grade? If so, please explain.

Is there a current IEP, 504 Plan or Individual Needs Accommodation Plan?Y or N (Circle)

If so, please attach a copy.

Please characterize your son/daughter’s

*Memory

*Organizational skills

*Concept of time

What does your son/daughter like to do in his/her leisuretime? Explain his/her hobbies/interests.

Has your son/daughter had any extended periods of absence from school due to illness, truancy, suspension, or expulsion? Explain.

Please describe any difficulty your son/daughter has in establishing and maintaining relationships.

Are there any activities you would like to have emphasized or see your child directed toward?

How does your child feel about the possibility ofattending Holy Rosary High School?

Why do you think HRS might be a good school for your child?

Is there anything that you would like to tell us about your child?

By submitting this form, I hereby grant permission to Holy Rosary to publish in print/video/film my child’s name, photograph, and/or likeness, spoken and/or written word in the following (Circle):

School yearbook/newspaper/brochureParish bulletin

Archdiocesan/local newspapersSchool/Parish/Archdiocesan website

TV/Radio

This agreement shall remain in force and effect at all times during my child’s enrollment at Holy Rosary School unless the school office is notified in writing.

This form was completed by:

_____Natural Parent

_____Legal Guardian

_____Adoptive Parent

Signature ______Date ______

Making a difference… one student at a time.

2437 Jena Street New Orleans, Louisiana 70115 Phone: 504.482.7173 Fax: 504.482.7229 Email: