Application Instructions

Blessed Francis Seelos AcademyPlease submit all forms given to you in order for the application to be completed.

All places for signatures must be signed.

APPLICANTS FOR Grades 1 through 8 should fully complete the enclosed pages.

We must have a copy of the following:

Child’s Birth Certificate

Child’s Baptismal Certificate

Child’s Immunization Record

Child’s Report Card for Current Year-to-Date

Any pertinent Custody Papers (if applicable)

In addition, please take the “Request for Records” form and submit it to the student’s present school. This givesthat school permission to forward all scholastic and health records to us.

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Blessed Francis Seelos Academy reserves the freedom to evaluate your child’s placementand academic success during the first quarter of the fall term,

so that the needs of your child can be totally met.

All applications should be turned in to the Blessed Francis Seelos Academy office along witha non-refundable deposit of $200 payable to Blessed Francis Seelos Academy.

This will be deducted from your family’s first month’s tuition payment.

No application will be considered completeuntil ALL FORMS AND PAYMENTS are submitted to the school office.

Financial Aid Applications Available ONLINE ONLY at the following link: https://diopitt.org/affordable

Deadline for Financial Aid Applications is March 15, 2018.

Blessed Francis Seelos AcademyRegistration Form

201 Church Road, Wexford, PA 15090Office: (724) 935-1152 Email: seelosacademy.org

STUDENT DATA (Please Print Clearly) ENTERING GRADE: � K � 1 � 2 � 3 � 4 � 5 � 6 � 7 � 8

Student’s Last Name: First: Middle:

Address: Male/Female:

City: State: Zip: Phone:

Date of Birth: Place of Birth: Age as of September 1:

Public School District of Residence (Taxes paid to:) Public School Building this student would attend, if not enrolled here:

Religion: Parish where registered:

Ethnicity: � African-American � Hispanic � Asian � Native American � Caucasian � Multi-racial � Pacific Island � Other

Current School: Address of Current School:

FAMILY DATA (Please Print Clearly)

MOTHER (First, Maiden & Last) FATHER

Name: Name:

Address if different from student: Address if different from student:

Home Phone: Home Phone:

Cell Phone: Cell Phone:

E-mail: E-mail:

Occupation: Occupation:

Employer: Employer:

Business Phone: Business Phone:

Religion: Religion:

Parish where registered: Parish where registered:

Catholic School Alumni � Yes � No Catholic School Alumni � Yes � No

Student resides with: � Both Parents � Mother only � Father only � Joint Custody � Other

Parents/Guardians Marital Status: � Married � Separated � Divorced � Widowed � Single Parent

Please list any talents or interests you will be willing to share with the school:

If mail is to be sent to a second address, please complete:

Name:

Address:

Relationship:

GUARDIANSHIP (If Applicable)

CUSTODY: A legal document stating guardianship must be provided in cases of divorce with sole and/or shared custody.

Student’s legal guardian (if other than parent): __________________________________________________________________Relationship to the student: __________________________________________________________________________________

SIBLINGS UNDER 18 (Oldest to Youngest):

Name Male / Female Date of Birth

1.

2.

3.

4.

SACRAMENTAL INFORMATION of Applicant:

Date Church City and State

Baptism

Reconciliation

Holy Eucharist

Confirmation

Please return this Application with a non-refundable deposit of $200.00. (This will be applied towards your first tuition payment).

Checks and money orders should be made payable to; Blessed Francis Seelos Academy201 Church RoadWexford, PA 15090

The following must also be submitted with each child’s registration:� Birth Certificate � Baptismal Certificate � Immunization Records

No application will be considered complete until ALL FORMS AND PAYMENTS are submitted to the school office.

For office use only: Date: _______________ � Check # ____________ � Cash

New and transferred students are accepted on a probationary basis (90 school days). New students and their families shouldbe cognizant of, and willing to comply with, all school expectations. If problems arise during the probationary period which havenot been resolved, the student will be required to transfer.

Student’s Name:

In order to provide the best education for your child, please complete the following:

Has your child ever:

1. Had a psychological evaluation? � Yes � No

2. Been diagnosed with any of the following:� LD (Learning Disability) � ADD (Attention Deficit Disorder) � ADHD (Attention Deficit Hyperactive Disorder) � ASD (Autism Spectrum Disorder) � ODD (Oppositional Defiant Disorder) � Other ____________________________Does your child take medication associated with this diagnosis: � Yes � No

3. Received any of the following services:� Counseling � Emotional Support � Gifted Support � Remedial Math � Remedial Reading� Speech/Language � Project Dart � Learning Support � Other ___________________________________________

4. Had an IEP? � Yes � No If yes, what is the disability? ___________________________________________________Please submit a copy of the IEP.

5. Been diagnosed with a medical condition that the school should be aware of? � Yes � NoIf yes, please explain. _____________________________________________________________________________________

_________________________________________________________________________________________________________

6. Repeated a grade? � Yes � No If yes, which grade? _____________ Why? ____________________________________

_________________________________________________________________________________________________________

7. Received a suspension from school? � Yes � No If yes, please explain. ______________________________________

_________________________________________________________________________________________________________

8. Been asked to transfer? � Yes � No If yes, please explain. _________________________________________________

_________________________________________________________________________________________________________

9. Been expelled from school? � Yes � No If yes, please explain. ______________________________________________

_________________________________________________________________________________________________________

I hereby give permission for _________________________’s information to be released from his/her school into the possessionof NHRCES. (Child’s name)

Parent/Guardian Signature ___________________________________________________ Date __________________________

NHRCES is unable to honor IEPs or 504 Plans. Such documents, as well as school psychological evaluations, discipline files,court involvement, educational evaluations and standardized test results must be shared with the school in order to completeapplication. Omissions may nullify acceptance.

No application will be considered complete until ALL FORMS AND PAYMENTS are submitted to the school office.

BLESSED FRANCIS SEELOS ACADEMYHOME LANGUAGE SURVEY

The Office of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS identify limited Englishproficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylva-nia has selected the Home Language Survey as the method for the identification.

Student’s Name: ___________________________________________________ Grade: ______________

1. What is/was the student’s first language? __________________________

2. Does the student speak a language(s) other than English? q Yes q No

(Do not include languages learned in school.) If yes, specify the language(s): ____________________________

3. What language(s) is/are spoken in your home? ______________________

Parent/Guardian initial: ____________________

*The school district/charter school/full day AVTS has the responsibility under the federal law to serve studentswho are limited English proficient and need English instructional services. Given this responsibility, the school district/charter school/full day AVTS has the right to ask for the information it needs to identify English LanguageLearners (ELLs). As part of the responsibility to locate and identify ELLs, the school district/charter school/full dayAVTS may conduct screenings or ask for related information about students who are already enrolled in theschool as well as from students who enroll in the school district/charter school/full day AVTS in the future.

CERTIFICATE OF INDIVIDUAL REQUESTFOR LOAN OF TEXTBOOKS AND INSTRUCTIONAL MATERIALS

(This simply states your awareness that Pennsylvania tax monies are used in order to purchase textbooks.)

I hereby request the loan of textbooks and instructional materials in accordance with Pennsylvania Act 195 andAct 90 for my child(ren) attending St. Alphonsus School.

Student Names: ______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Date: _______________________________ Signed: ___________________________________________(Parent or Guardian)

Catholic School Parents Memorandum of Understanding

As a parent/guardian of a student in a Catholic school, I understand, affirm, and support the following:

1. The primary purpose of a Catholic school education is to form students in the values ofJesus Christ and the teaching of the Catholic Church.

2. Catholic schools are distinctive religious education institutions operated as programs ofthe Catholic Church; they are not private schools but are administered and supported by the sponsoring parish(es), the diocese, or religious community.

3. Attending a Catholic school is a privilege, not a right.

4. While academic excellence and involvement in extracurricular activity (i.e., sports, clubs, etc.) are important, fidelity to the Catholic identity of the school is the fundamental priority.

5. The school and its administration have the responsibility to ensure that Catholic values and moral integrity permeate every facet of the school's life and activity.

6. In all questions involving faith, morals, faith teaching, and Church law, the final determinationrests with the diocesan bishop.

As a parent/guardian desiring to enroll my child in a Catholic school, I accept this Memorandum ofUnderstanding. I pledge support for the Catholic identity and mission of this school and by enrolling my childI commit myself to uphold all the principles and policies that govern a Catholic school.

Father: ________________________ Mother: ________________________ or Guardian:______________________(please print) (please print) (please print)

________________________________ ________________________________ __________________________________(signature) (signature) (signature)

______________________________________________________Student’s Name (please print)

______________________________________________________Date

This application and registration fee must be accompanied by a copy of the child’s required forms as well asany custody papers (if applicable) in order to be considered complete.

County of Allegheny Health Immunization Regulations

Allegheny County’s School Health Immunization Regulation, Article X, requires that all schools are to determine theimmunization status of every student registered in their district prior to admission to school. The Allegheny CountyHealth Department (ACHD) established new vaccine requirements in September of 2008 to further protect our youth.These vaccines include:

ALL GRADES K-124 doses of tetanus (1 dose after the 4th birthday); 3 doses if series started after 7 years of age4 doses of diphtheria (1 dose after the 4th birthday; 3 doses if series started after 7 years of age3 doses of polio2 doses of measles2 doses of mumps1 dose of rubella3 doses of hepatitis B2 doses of varicella or written statement from physician/designee indicating monthand year of disease or serologic proof of immunity

GRADES 7-121 dose of tetanus/diphtheria/pertussis (Tdap)1 dose of meningitis vaccine (MCV4)

The school vaccination requirements apply to all public, private, parochial, cyber and home-school students in Allegheny County. Students who are entering Allegheny County schools for the first time (Kindergarten or studentstransferring from out of county) are subject to the following provisions:

i Exclusion from school attendance of a child who lacks a single dose of a single dose vaccine and/or the firstdose of a multiple dose vaccine:

i Allowing a child who needs the next or final dose of a multiple dose vaccine to provisionally attend school if thechild obtains the next or final dose within the first five school days:

i Allowing a child needing more than one dose of a multiple-dose vaccine series beyond the first five school daysto attend school provisionally upon the submission of a medical certificate from the child’s health care provider outlining the dates for additional vaccination;

i Allowing school administrators to exclude a child who does not comply with the dates in the submitted medicalcertificate;

i Students without proof of vaccination are to be excluded at the start of the school year, unless their parent obtains an exemption for medical or religious reasons.

Because MCV4 and Tdap immunizations are not a series, there is no provisional enrollment period. Students ingrades 7-12 must have VCV4 and Tdap (if 5 years have elapsed since the last tetanus immunization). No provisionalenrollment will be extended to these students.

MEDICATION POLICY:

If a child must take an over-the-counter medication - it must be sent to school in the original package, accompaniedby written permission from the parent, with a doctor’s order. This includes over-the-counter medications.

Prescribed medication should be taken at home. If necessary, the school office staff may administer medicinalpreparations in the original container with proper pharmacy labeling (child’s name, medication name, dosage, administration directions and pharmacy identification) which are accompanied by a physician’s orders with the parent’s permission. Unlabeled medications will not be given under any circumstances.

BLESSED FRANCIS SEELOS ACADEMYHEALTH SCREENING PROGRAM

Dear Parents:

It is the policy of the Pine-Richland School District to comply fully with all State mandatedmedical and dental examinations required for school age children. These include:

i Each child be given a vision test annually.

i Each child in kindergarten, first, second, third, and seventh and eleventh grades be given a hearing test.

i Each child be weighed, measured, and BMI (Body Mass Index) calculated yearly

i Scoliosis screening for sixth and seventh graders.

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The School Health Act of Pennsylvania also requires that:

i Each child have Physical examinations in kindergarten or first grade (new enterers),and sixth grade.

i Each child have Dental examinations in kindergarten, third and seventh grades.

We prefer you have these exams done by your family physician/dentist, but if private care is not possible, the school district will provide these exams at Blessed Francis Seelos Academy. If your childneeds the school exams, you will be notified in advance.

Children whose dental or physical examination reports are not returned completed byOctober 1 will be scheduled for the examination at school. Thank you for your cooperation.

This health screen program form will be valid throughout the child’s entire time in Pine-RichlandSchool District.

I understand that my child ________________________________ will be given the full services as indicated as required above. I understand I will be notified of any matters needing attention.

_________________________________________________ _______________________________________PARENT / GUARDIAN SIGNATURE DATE

1/13

REQUEST FOR SCHOOL AND HEALTH RECORDS

The following student has registered at Blessed Francis Seelos Academy - NHRCES

NAME ___________________________________________________________ GRADE ___________

NAME AND ADDRESS OF SCHOOL THAT STUDENT HAS BEEN ATTENDING:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

PLEASE FORWARD: HEALTH & DENTAL RECORDS, STANDARDIZED TEST RESULTS, GRADES, REPORTS, ETC.

PARENT’S SIGNATURE DATE

RECORDS TO BE SENT TO: Blessed Francis Seelos Academy - NHRCES201 Church RoadWexford, PA 15090(724) 935-1152

Blessed Francis Seelos Academy201 Church Road, Wexford, PA 15090

Office: (724) 935-1152 Email: seelosacademy.org