Application For Admission Form - Diocese Of Arlington Page 2
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3Diocese of Arlington
Application for Admission
Name and Address of person responsible for tuition/fees payment:
Name
Home Address
City
State
Zip
Marital Status:
Married
Single
Separated
Divorced*
Mother deceased
Father deceased
Father remarried
Mother remarried
*
Note: In the event of a divorce, decree of custody must be filed in the school office, as well as any specific instructions
regarding release of the child to a parent.
Grandparent Information:
Paternal
-
-
: Name
Phone
Home Address
City
State
Zip
Maternal
-
-
: Name
Phone
Home Address
City
State
Zip
Student lives with:
Both Parents
Mother
Father
Guardian (if checked, fill out below)
-
-
-
-
Guardian Name
Phone
Cell Phone
Home Address
City
State
Zip
-
-
Occupation
Employer
Work Phone
Religion
Parish
Has your student ever been suspended, dismissed, expelled, or not permitted to re-enroll in a school?
yes
no
If yes, please give the name of the school and explain the reasons on a separate sheet of paper.
Has your student ever been tested or evaluated for any disability [i.e., Learning Disabilities, Attention
Deficit (Hyperactivity) Disorder, Emotional Disabilities, etc.], English as a Second Language, or medical
condition?
yes
no
If yes, please describe on a separate sheet of paper any disability or medical condition that may affect the applicant’s
ability to fully participate in the academic and/or other programs provided at our school. If applicable, please provide
dates of IEP, Student Assistance Plan, Special Ed Child Study, Special Ed Eligibility Date from base public school and
Special Ed Triennial.
If you are requesting an adjustment or accommodation to allow participation to any program, please
describe your request. Please provide sufficient evidence to allow us to assess your situation. We may
request additional information from you and from an appropriate health professional.
Information about disabilities is requested for the sole purpose of determining whether the school can
provide the applicant with an appropriate education or reasonable accommodation and will not be
considered in determining whether he/she is otherwise qualified for admission.
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Diocese of Arlington Office of Catholic Schools 2009
Page
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