St. Brigid School
695 Stevens Avenue, Portland, ME 04103
Tel. (207) 797-7073 Fax (207)
797-7078
www.sbrigids.com
Application Date: ________________
There is a $200 (per family)
application fee when submitting this form to our school office.
If there is no space available, the
application fee will be refunded.
A COPY OF IMMUNIZATIONS AND BIRTH CIRTIFICATE MUST ACCOMPANY REGISTRATONS FOR ALL NEW STUDENTS TO THE SCHOOL
STUDENT’S
FULL NAME
(Please Print)
Gender Date
of Birth
Entering
_________________________________________________________
M / F
____/____/___
______
_________________________________________________________
M / F
____/____/___
______
_________________________________________________________
M / F
____/____/___
______
Primary Home Street Address ____________________________________________________________
Parent or Guardian and Contact Information:
Mother’s/Guardian’s Full Name
________________________________________ Religion ______________
(Last)
(First)
(M I) Maiden Name_________________
Home Street Address
__________________________________________________________________
If
different from above, should correspondence be sent to both addresses?
_____yes _____
no
City/Town _________________
State _____ Zip__________
Email Address _________________
Place of Employment ___________________________________________________
Home Phone
_________________ Cell
Phone____________________ Work Phone________________
Father’s/Guardian’s Full Name
_______________________________________
Religion __________________
(Last)
(First)
(M I)
Home Street Address
_____________________________________________________________________
If
different from above, should correspondence be sent to both addresses?
_____yes _____
no
City/Town _________________ State _____ Zip__________
Email Address _____________________
Place of Employment ___________________________________________________
Home Phone _________________ Cell Phone____________________ Work Phone________________
| Student Lives With: |  Mother |
Stepmother |
 Father |
Stepfather |
 Legal
Guardian |
Other |
THE FOLLOWING INFORMATION WILL BE USED TO
COMPLETE REQUIRED STATE & FEDERAL REPORTS.
LANGUAGE SPOKEN AT HOME, IF OTHER THAN ENGLISH: _____________________
| Ethnic: |
Other/Not Provided (X) |
White/ Caucasian (C) |
African American/ Black (B) |
Asian/ Pacific Islander (A) |
American Indian/ Native Alaskan (I) |
 Hispanic (H) |
DISMISSAL
CONSENT:
May the
adults on this form dismiss this student in case of
emergency ___Yes ___ No
If no, please attach a note with details on which adult may or may not dismiss
this pupil
If parents are divorced, what is the custody
status of the pupil? (Please check
one)
___
Custody to Mother ____Joint Custody ___Custody to Father
____Other, Please Explain __________________
In case of an
accident and the school is unable to contact anyone, do you have a hospital
preference: ____________________
Is your child covered by insurance? ___Yes
___No
HEALTH & SPECIAL EDUCATION INFORMATION
Does this student have any health problem of which the school should be aware? __Yes __No
1.
2.
Has the student ever received Special Education Services?
__Yes __No
Is the student receiving Special Education Services
presently? __Yes __No
Please explain :
_____________________________________________________________________
____________________________________________________________________________
Parish Where
Registered/Affiliated __________________________________________________________
School & Address last
attended (If applicable) _________________________________________________
(Name of School)
Are you a graduate from a Catholic School?
__Yes __No
School ______________________ Year ______________