St. Clement School 4534 Vine Street • St. Bernard, Ohio 45217 • 513-641-2137 ST. CLEMENT SCHOOL REGISTRATION FORM Date:_________ Child’s Name:__________________________________________ Entering Grade: _____________ Home Address: ________________________________________ Apt. #.: ____________________ City: _________________________ State: ______________ Zip Code: __________________ Birth date: ____/____/____ Birthplace:___________________ Home Phone #: ______________ Child’s Social Security Number: __________________________________________________________ Previous School: ____________________________________________ Present Grade: ___________ Address: _______________________________ City, State, Zip Code:__________________________ Other Schools Attended: (Name and Address) __________________________________________________________________________________ __________________________________________________________________________________ Sex: Male: ______ Female: ______ American Citizen: Yes_____ No ______ Race: American Indian _____ Asian _____ Black _____ Hispanic _____ White _____ Multi Racial _____ Child’s Religion: Catholic:______ Other: (Please specify): __________________________ Sacraments: Baptism First Communion Confirmation Date: __________________ __________________ __________________ Church: __________________ __________________ __________________ City, State: __________________ __________________ __________________ Support Programs. Check ALL the programs below in which the child has or is currently participating. _____ Remedial Math _____ Speech/ Language _____ Gifted Program _____ Remedial Reading _____ D.H. Tutor _____ Other:________________ _____ L.D. Tutor _____ Tutor Privately Mother’s Name:__________________________________________ Religion:______________________ Home Address, if different from child’s:_______________________________________________________ City:________________________ State:________________________ Zip Code:__________________ Home Phone #:_________________________ Place of Employment:______________________________ Address:__________________________________________________ _ Business Phone #:_____________ *************************************************************************************** Father’s Name:___________________________________________ Religion:______________________ Home Address, if different from child’s:_______________________________________________________ City:________________________ State:_______________________ _ Zip Code:__________________ Home Phone #:_________________________ Place of Employment:______________________________ Address:___________________________________________________ Business Phone #:____________ *************************************************************************************** Legal Parents: _____ Both Parents at home _____ Grandparents _____ Foster Parent _____ Mother only _____ Guardian _____ Adoped _____ Father only _____ Stepfather only _____ Other ________________ _____ Mother & Stepfather _____ Stepmother only _____ Father & Stepmother _____ Joint Custody, more than one home *************************************************************************************** Emergency person to contact:_______________________________________________________________ Daytime phone #:____________________________ Relation to child:_____________________________ Baby-sitter after school or Daycare provider, if applicable:________________________________________ _____________________________________________ Phone #:__________________________________ *************************************************************************************** ______ Registered in St. Clement Parish ______ Registered in St. Bernard, New Jerusalem ______ Registered in another Catholic Parish ______ Not Registered in any Catholic Parish
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St. Clement School, 4534 Vine St. St. Bernard, OH 45217