New Student Application

Student Name (First, Middle, Last) REQUIRED Please fill out this field. Please enter valid data.

Birth Date REQUIRED Please fill out this field. Please enter a date.

School Year REQUIRED Please fill out this field.

Entering Grade Level REQUIRED Please fill out this field.

Preschool Selection

Catholic Parish or Other Place of Worship Please enter valid data.

Our family is not Catholic We might be interested in becoming Catholic We are not interested in becoming Catholic at this time

Country of Birth REQUIRED Please fill out this field. Please enter valid data.

Gender REQUIRED Please fill out this field.

Religion Please enter valid data.

My child has received all required, age-appropriate vaccinations* for attendance in a Pennsylvania school. REQUIRED Please fill out this field.

*CLICK HERE for Pennsylvania's School Vaccination Requirements.

Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Primary Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Primary Email Address REQUIRED Please fill out this field. Please enter valid data.

Current School Please enter valid data.

Public School District of Residence REQUIRED Please fill out this field. Please enter valid data.

County REQUIRED Please fill out this field. Please enter valid data.

Student Ethnicity REQUIRED Please fill out this field.

Student Race REQUIRED Please fill out this field.

Mother/Guardian's Name Please enter valid data.

Religion Please enter valid data.

Country of Birth Please enter valid data.

Father/Guardian's Name Please enter valid data.

Religion Please enter valid data.

Country of Birth Please enter valid data.

Parents/Guardians are REQUIRED Married Separated* Divorced* Single Deceased-Mother Deceased-Father Please fill out this field.

*Custody papers must be submitted when you visit the school to complete the registration process.

Home Situation of Student (check all that apply) REQUIRED 2 Biological Parents 1 Parent/Guardian Father/Stepmother Mother/Stepfather Other Please fill out this field.

Please list stepparents, guardians, or addresses of parents if different from what is already listed. Please enter valid data.

Street Address Please enter valid data.

City Please enter valid data.

State

Zip Please enter a zip code.

Phone Number Please enter a phone number.

Please List Other Siblings (Name, Date of Birth, Grade if in School) Please enter valid data.

Sacramental Information for Registering Student (if applicable)

Baptism (Date, Church, City, State) Please enter valid data.

First Penance (Date, Church, City, State) Please enter valid data.

First Eucharist (Date, Church, City, State) Please enter valid data.

Confirmation (Date, Church, City, State) Please enter valid data.

Has your child been been given or referred for an educational evaluation? REQUIRED Please fill out this field.

Does your child receive services such as speech, physical therapy, or occupational therapy? REQUIRED Please fill out this field.

*If yes, please list services. Please enter valid data.

Does your child have a current ER (Educational Report)? REQUIRED Please fill out this field.

Does your child have an IEP (Individualized Education Program) or GIEP (Gifted Individualized Education Program)? REQUIRED Please fill out this field.

Does your child have a 504 Plan? REQUIRED Please fill out this field.

*If your child has an ER, IEP GIEP, or 504 Plan, please email the document to advancement@simonandjude.org for review.

Does your child receive support services in reading or math? REQUIRED Please fill out this field.

*If yes, please list services. Please enter valid data.

Additional Comments