Thank you for applying to St



Thank you for applying to St. Theresa School! Please fill out one application per child. Complete all sections, indicating “N.A.” if something does not apply. Please print, enclose a $75 application fee and return to the school office.

GRADE APPLYING FOR:________

Child’s Name:

| | | |

last name first name middle name

Address:

| | | | |

number and street name city state zip

|Home Phone: ( ) |Child’s citizenship: ☐ U.S., native-born ☐ U.S., naturalized ☐ Other |

|Gender: ☐M ☐F |Age: |Date of birth: |Place of birth: |

|# of siblings: Age(s): |Grade(s) of sibling(s) currently enrolled at St. Theresa School: |

Child is presently living with:

☐ both natural parents ☐ mother and stepfather ☐ father and stepmother ☐ single parent mother

☐ single parent father ☐ other- please explain

________________________________________________________________________________________________________

If shared custody, please explain custody arrangement:

_________________________________________________________________________________________________

Were you referred to St. Theresa School by one of our current families?

Family name:

_________________________________________________________________________________________________________

How did you hear about St. Theresa School? (Check all that apply.)

☐ Parish bulletin ☐ Friend ☐ Preschool ☐ Newspaper ☐ Website ☐ Other___________________

Father/Guardian: Mother/Guardian:

First Name: __________________________________________ ____________________________________________

Last Name: __________________________________________ ____________________________________________

Address: __________________________________________ ____________________________________________

City, State, Zip: __________________________________________ ____________________________________________

Email Address: __________________________________________ ____________________________________________

Home Phone: __________________________________________ ____________________________________________

Cell Phone: __________________________________________ ____________________________________________

Business Phone: __________________________________________ ____________________________________________

Occupation: __________________________________________ ____________________________________________

Employer: __________________________________________ ____________________________________________

Religion: __________________________________________ ____________________________________________

Baptized: ☐ Roman Catholic ☐ Other ☐ Roman Catholic ☐ Other

Alumni? ☐ Yes__________________(year) ☐ No ☐ Yes__________________(year) ☐ No

US Citizen? ☐ Yes ☐ No ☐ Yes ☐ No

Date Church City, State/Country

Child's Baptism: _________________ ___________________________ ________________________________________

Child's 1 st Eucharist:_________________ ___________________________ ________________________________________

Are your currently registered with a parish? ☐ Yes ☐ No

If yes, which parish _________________________________________________________________________________________

How long? _________________________________________________________________________________________

In which parish organizations do you and your family participate?

_________________________________________________________________________________________________________

Does your child attend Faith Formation Classes? ☐ Yes ☐ No

If yes, which parish _________________________________________________________________________________________

Are you willing to reinforce the values taught at St. Theresa School through religious studies including liturgy participation, student retreats and our Service Learning program? ☐ Yes ☐ No

Please include preschool through current schooling.

School City Grade(s How long?

_________________________________________________________________________________________________________

(currently attending)

_________________________________________________________________________________________________________

(previously attended)

Has your child been retained? ☐ Yes ☐ No If yes, what grade? ____________________________

Has your child ever been identified or tested for special needs? ☐ Yes ☐ No

(If yes, please check box[es) below and attach copies of formal educational assessment, and IEPs if applicable.)

☐ Attention ☐ Auditory ☐ Learning ☐ Speech ☐ Visual ☐ Other

Has your child ever experienced any behavioral or disciplinary issues? ☐ Yes ☐ No (If yes, please explain)

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Why are you considering moving your child from his/her current school? (Grades 1-6 only)

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Why might St. Theresa School be the right school for your child? Please include aspects of a school you believe are most important and your reasons for choosing St. Theresa School.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

What are your child’s strengths and challenges?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Describe your child’s relationship with his/her peers.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

In what ways have you been involved in or supported your child’s present school?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

For your child’s safety, does he/she have any medical conditions we should be aware of? ☐ Yes ☐ No

If yes please indicate: _________________________________________________________________________________________________________

Is there any other information you’d like to share?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

I certify that the enclosed information is correct to the best of my knowledge.

☐ I have attached my child’s most recent report card / progress report.

☐ I have attached my child’s recent standardized test scores. (Grades 2-6 only)

☐ I have enclosed the $75 non-refundable application fee, made payable to “St. Theresa School.”

☐ I have attached a recent photo of my child.

Father/Guardian signature: __________________________________________________________ Date: ___________________

Mother/Guardian signature: __________________________________________________________ Date: ___________________

St. Theresa School does not discriminate on the basis of race, color, national or ethnic origin, age, sex or disability in the admission of students or the administration of educational policies, scholarships and other school-administered programs.

For office use only:

REPORT CARD |TEST SCORES |PARISH STATUS |BIRTH CERTIFICATE |BAPTISMAL CERTIFICATE |STUDENT PHOTO |FEE | |

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Student Application

2017/18 SCHOOL YEAR

STUDENT INFORMATION

FAMILY INFORMATION

ACADEMIC INFORMATION

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4850 Clarewood Drive, Oakland, CA 94618 | 510.547.3146 |

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