st. mary catholic school...st. mary catholic school 2351 22nd avenue, greeley, co 80631 tel....
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St. Mary Catholic School 2351 22nd Avenue, Greeley, CO 80631
Tel. 970-353-8100 • Fax 970-353-8700 “The child continued to grow and become strong, filled with wisdom;
and the grace of God was upon him” (Lk 2:40)
Returning Student Registration Guidelines 2020 - 2021 Academic School Year
Welcome In this registration packet you will find tuition rates and fees for the 2020-2021 school year. There is a non-refundable registration fee of $225 per family due with this application. There is also a non-refundable $150.00 book rental/supply fee per student due by August 1, 2020. Please look over everything in this packet carefully. St. Mary endowment fund information will be available upon request. If you think you qualify, please ask the school for an application. Your registration will be complete when the following items are turned into the school office. Please fill out each form completely.
Registration will not be accepted until all items are turned in and completed in its entirety. (The Family Out-of-Parish Affiliation form can be turned in at a later date, upon pastor signature.)
Application for Admission for Returning Students (one per family) Parish Affiliation Confirmation (one per family) Please fill out the form that applies:
~ St. Mary Affiliation Confirmation form- to be filled out by St. Mary parishioners or ~ Family Out-of-Parish Affiliation form - to be filled out by parishioners of all surrounding parishes.
Please take this form to the parish in which you belong. You will be charged the Non-Catholic rate until we receive this form signed by your Pastor. The parish will either give you the signed form or return it to our office once signed.
(Application may be submitted to the school prior to receiving the parish affiliation form.)
Financial Contract (one per family)
Emergency Card (one for each child)Health Questionnaire (one for each child)Permission Sign-Off/Dismissal Information form (one per family)
Permission for Publication of Information/Photograph and Interview Release form (one per family) Care Application and Care Contract (one per family)A Copy of updated immunization record, if applicable
$225 registration fee per family - DUE AT TIME OF APPLICATION.
If filling this application by computer, please download and save before entering information.
To complete your registration as a downloadable PDF you must complete the following:
The Catholic schools of the Archdiocese, under the jurisdiction of the Archbishop, and at the direction of the Superintendent, attest that none of the Catholic schools discriminates on the basis of sex in its admission policies, its treatment of students or its employment practices. Notice of Student Non-Discrimination Policy The Catholic schools of the Archdiocese of Denver, under the jurisdiction of Archbishop Samuel J. Aquila, S.T.L. and at the direction of the Superintendent, state that all of their Catholic schools admit students of any race, color, national or ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the schools. Furthermore, Archdiocesan schools admit disabled students in accord with the policy on Admissions in the Archdiocese of Denver Catholic Schools Adminis-trator’s Manual. These schools do not discriminate on the basis of race, age, disability, color, and national or ethnic origin in the administration of their educational policies, employment practices, scholarship and loan programs, athletic or other school-administered programs.
Please download this form, ÓÁÖÅ, fill out and ÓÁÖÅ again before making your online payment. (Make sure you save periodically.)
1. Digital signatures are required on all forms.Click on How to Sign the Registration Form Digitally for instructions..ÏÔÅ: Every time you apply a digital signature it will prompt you tosave your forms.
2. Provide requested document (i.e. updated immunization records…)
3. Print out the parish affiliation form that pertains to your family andsubmit to your pastor for his signature. St. Mary parishioners mayreturn their affiliation form with their registration packet.(Registration packets may be submitted to the school prior toreceiving the signed parish affiliation form.)
4. Submit all forms to the office either through FastDirect, by yourpersonal email to [email protected] or a printed copy, and
5. $225.00 registration fee (per ÆÁÍÉÌÙɊ either by check made payableto St. Mary Catholic School or pay online by clicking the link below. Ifpaying online please provide a copy of the receipt.
Thank you for registering at St. Mary Catholic School!
St. Mary Catholic School
Application for Admission for Returning Students 2020-2021 Academic School Year
One form per Family
(Church or Parish)
Grade Male Female Birth Date
Student’s Name
Birth Place
*Child’s Name and Grade level for school year 2020-2021Grade
Male Female Birth Date Student’s Name
Birth Place
*Child’s Name and Grade level for school year 2020-2021Grade
Male Female Birth Date Student’s Name
Birth Place
*Child’s Name and Grade level for school year 2020-2021Grade
Male Female Birth Date Student’s Name
Birth Place
Please provide AT LEAST ONE email address so that St. Mary Catholic School can communicate important information to your family:
_______________________________
Family Name: _____________________________
Religious Affiliation Father's Affiliation Mother's Affiliation
Registered Member of
Please type or print in black ink and answer all questions completely.
*Child’s Name and Grade level for school year 2020-2021
________________________________ E-mail Address
All papers in the Wednesday Communication Envelope
Electronically by way of FastDirect (school online communicaiton system)
How would you like to receive the Parent Newsletter? (Choose one)
E-mail Address
m/d/yyyy
m/d/yyyy
m/d/yyyy
m/d/yyyy
City & State
City & State
City & State
City & State
St. Mary Catholic School
Family Name Family Background
Applicant lives with (Check those that apply): Father Mother Stepfather Stepmother Other Marital Status
Please check if applicable: Father Deceased Mother Deceased
*Court Custodial agreement needs to be on file (If applicable) All school communications will be sent to the address at which the student resides. If parents or step-parents not living with the student wish to be included on the St. Mary’s mailing list, please provide information.
Has you child ever been evaluated for Special Education Services/IEP? Yes No
If yes, explain for each child:
Does you child take any regular medication? Yes No
If yes, explain and list child’s name:
Does your child have any medical concerns/disabilities that the school should be made aware of? Yes No
If yes, explain and list child’s name:
Information for St. Mary Catholic School and Archdiocesan use only: Please check the appropriate box in both columns:
Student’s Race Background: Student’s Ethnic Background: Hispanic/Latino Non-Hispanic/Latino
Native American Black Asian White Hawaiian/Pacific Islander Multi-Racial (please list all races) ___________________________ Other (please indicate) ____________________________________
I hereby certify that the information presented on this form is true, accurate and complete. I understand that it is my responsibility to update any and all information as it changes.
Signature of Father or Guardian Date Signature of Mother or Guardian Date
A check for the registration fee of $225.00 should accompany this application. This is a non-refundable fee. The Catholic schools of the Archdiocese, under the jurisdiction of the Archbishop, and at the direction of the Superintendent, attest that none of the Catholic schools discriminates on the basis of sex in its admission policies, its treatment of students or its employment practices. Notice of Student Non-Discrimination Policy The Catholic schools of the Archdiocese of Denver, under the jurisdiction of Archbishop Samuel J. Aquila, S.T.L. and at the direction of the Superintendent, state that all of their Catholic schools admit students of any race, color, national or ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the schools. Furthermore, Archdiocesan schools admit disabled students in accord with the policy on Admissions in the Archdiocese of Denver Catholic Schools Adminis-trator’s Manual. These schools do not discriminate on the basis of race, age, disability, color, and national or ethnic origin in the administration of their educational policies, employment practices, scholarship and loan programs, athletic or other school-administered programs.
If any of these questions pertain to more then one child, please list each child's names next to their information. Please answer the questions below:
St. Mary Catholic School Financial Contract
2020 - 2021 Academic School Year Evaluated Midyear for Adherence
Method of Payment:
It is the responsibility of all parents to pay their tuition on a timely basis. If your tuition is not paid by the 20th day of the month, further action will be taken. If more than one mailing address is required, a $20 charge will be added for each additional address.
St. Mary Catholic Education Foundation Greeley endowment fund is available for qualifying families. If you are applying to the endowment fund for tuition assistance, applications must be returned to Susan Benke, Business Manager, by April 30, 2020. All applications must include copies of your income tax return.
If you receive assistance or any other discount, fundraising and volunteerism requirements must be met. Status of both factors will be evaluated mid-year.
If your tuition for this school year is not current, you will not be allowed to register for next year until it is brought up to date.
Fees: All Non Refundable Registration Fee: Book Rental & Supplies:
$225.00 per family, due at registration $150.00 per child, due August 1, 2020
Tuition: Kindergarten through Eighth Grade _____*Catholic Families (In “Good Standing” with your parish) Initial First Child Second Child Third Child Fourth Child
$4,450.00 $4,250.00 $4,050.00 Free *If you are not recognized as an active, contributing member of your parish, you will becharged the Non-Catholic/No Parish Affiliation rate
_____*Non-Catholic or no Parish Affiliation Initial First Child Second Child Third Child Fourth Child
$6,100.00 $5,900.00 $5,700.00 Free
*Catholics in “Good Standing”: It is the responsibility of all Catholic parents to be in “Good Standing” within their parish.To be a Catholic in Good Standing you must do the following:
• Be registered at your parish• Attend Mass on a regular basis• Give of your treasure to your parish by check or envelope• Give of your time to your parish in a volunteer capacity
(You must have the parish affiliation form signed to receive the Catholic rate)
1 of 2
Initial
Over
Family Name: ________________
_____Initial
Initial
______
I(We), ________________ _____________________, as the parent/guardian of ________________________, __________________________, __________________________, __________________________,at St. Mary Catholic School, choose the following payment option:
Payment made annually by September 16, 2020 with a 5% Discount
Payment made in three equal installments (September 16th, December 16th and March 16th)
Payment made monthly on the 10th or 20th of the month.
______
______Initial
St. Mary Catholic School
Fundraising Goals
In order to keep tuition affordable, all parents are asked to participate in the school fundraisers. Tuition will have to be raised to meet the financial needs of the school if fundraising goals are not met. The ideal amount needed per family remains $976.
- Purchasing $5,000 of Script over the year, will bring $250 donation to the school. You can solicit help fromyour friends and family to help you raise this scrip amount. Scrip is available throughout the school year in the parish office Monday–Friday and through the Wednesday Communication Envelope. It may also be purchased in the parish office Monday-Thursday during the summer months. You may start purchasing scrip for the 2020-2021 academic school year on June 10, 2020.
- This year’s fundraising goal is $726, plus $250 in scrip donation, making the total fundraisingamount $976. You can reach your fundraising goal by participating in various fundraising events throughoutthe school year. Fundraisers are a part of St. Mary Catholic School. The school relies on participation tofund our school.
All parents are encouraged to give of their time to help with school activities, committees and other events.
Father/Guardian Name (Printed)
Mother/Guardian Signature Date
* This section, if applicable, will be completed upon approval of scholarship awarded.
Scholarship Addendum (Based on Need)
Tuition Amount $_________________
Scholarship Awarded $_________________
New Tuition Amount $ _________________
Father/Guardian Signature Mother/Guardian Signature Date
2 of 2
Pastor
Principal Business Manager
Date
Date
Mother/Guardian Name (Printed)
Father/Guardian Signature Date
Date
Date
St. Mary Catholic School
Health Questionnaire 2020-2021 Academic School Year
Please fill out completely, IF YOUR CHILD HAS HEALTH CONCERNS. Write “N/A” if your child has no health concerns.
Student’s Name _______________________________________
Date of Birth _______________________ Male Female
Parent’s/Guardian’s Name ______________________________ Phone Number __________________
Please list any health concerns the school should be aware of (i.e. Asthma, allergies, diabetes, physical limitations, etc): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
My child wears: Glasses Contacts Neither
List of Medications _________________________________________________________________________
(If medication is required at school an Authorization to Administer Medication & LAPP Authorization to Administer Medication in School must be filled out by parent and doctor.)
Dosage (times and quantities) ____________________________________________________________________________________Will medication need to be in the clinic at school? Yes No With the above listed health concerns, please list in order the actions you want taken if a related problem develops while your child is at school:
_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
________________________ _______________________________________________ Parent/Guardian Signature Date
Doctor’s Name ________________________________________ Phone Number __________________
I understand that I must keep my child's health and immunization records up to date with current information. If necessary, my child's health care provider may be contacted to update health and immunization records.
St. Mary Catholic School
Health Questionnaire 2020-2021 Academic School Year
Please fill out completely, IF YOUR CHILD HAS HEALTH CONCERNS. Write “N/A” if your child has no health concerns.
Student’s Name
Date of Birth
Parent’s/Guardian’s Name Phone Number
Doctor’s Name Phone Number
Please list any health concerns the school should be aware of (i.e. Asthma, allergies, diabetes, physical limitations, etc):
My child wears: Glasses Contacts Neither
List of Medications
(If medication is required at school an Authorization to Administer Medication & LAPP Authorization to Administer Medication in School must be filled out by parent and doctor.)
Dosage (times and quantities)
Will medication need to be in the clinic at school? Yes No With the above listed health concerns, please list in order the actions you want taken if a related problem develops while your child is at school:
I understand that I must keep my child's health and immunization records up to date with current information. If necessary, my child's health care provider may be contacted to update health and immunization records.
Parent/Guardian Signature Date
Male Female
St. Mary Catholic School
Health Questionnaire 2020-2021 Academic School Year
Please fill out completely, IF YOUR CHILD HAS HEALTH CONCERNS. Write “N/A” if your child has no health concerns.
Student’s Name
Date of Birth
Parent’s/Guardian’s Name Phone Number
Doctor’s Name Phone Number
Please list any health concerns the school should be aware of (i.e. Asthma, allergies, diabetes, physical limitations, etc):
My child wears: Glasses Contacts Neither
List of Medications
(If medication is required at school an Authorization to Administer Medication & LAPP Authorization to Administer Medication in School must be filled out by parent and doctor.)
Dosage (times and quantities)
Will medication need to be in the clinic at school? Yes No With the above listed health concerns, please list in order the actions you want taken if a related problem develops while your child is at school:
I understand that I must keep my child's health and immunization records up to date with current information. If necessary, my child's health care provider may be contacted to update health and immunization records.
Parent/Guardian Signature Date
Male Female
St. Mary Catholic School
Health Questionnaire 2020-2021 Academic School Year
Please fill out completely, IF YOUR CHILD HAS HEALTH CONCERNS. Write “N/A” if your child has no health concerns.
Student’s Name
Date of Birth
Parent’s/Guardian’s Name Phone Number
Doctor’s Name Phone Number
Please list any health concerns the school should be aware of (i.e. Asthma, allergies, diabetes, physical limitations, etc):
My child wears: Glasses Contacts Neither
List of Medications
(If medication is required at school an Authorization to Administer Medication & LAPP Authorization to Administer Medication in School must be filled out by parent and doctor.)
Dosage (times and quantities)
Will medication need to be in the clinic at school? Yes No With the above listed health concerns, please list in order the actions you want taken if a related problem develops while your child is at school:
I understand that I must keep my child's health and immunization records up to date with current information. If necessary, my child's health care provider may be contacted to update health and immunization records.
Parent/Guardian Signature Date
FemaleMale
St. Mary Catholic School Permission Sign-Off
2020-2021 Academic School Year
Child’s Name_______________________________ Child’s Name _______________________________ Child’s Name _______________________________ Child’s Name _______________________________ Please read the below items and indicate your permission for each item. Please be sure to initial after each item for which you give permission and sign the bottom of this sheet.
1. When accompanied by the teacher and class, my child has permission to walk to the Centennial ParkLibrary. (Located across the street on 23rd Avenue.) ................................................. (initial)
2. When accompanied by the physical education teacher and class, my child has permission to walk tothe Centennial Park Tennis Courts. (Located across the street on 23rd Avenue.) ...... (initial)
3. When accompanied by the physical education teacher and class, my child has permission to run/jogaround the outside perimeters of the church and/or school as a part of physical education class.Only Middle School students participate in this activity. ........................................ (initial)
Dismissal Information 2020-2021 Academic School Year
I give permission for my child/children to get home in the following ways: Name: Grade: Picked up Walk Ride bike
____________________________________ ______
____________________________________ ______
____________________________________ ______
____________________________________ ______
Parent/Guardian Signature Date
St. Mary Catholic School Permission for Publication of Information
2020-2021 Academic School Year We provide a variety of lists that include family address and telephone number. (Family Directory, etc.) If you prefer that your phone number and/or address not be provided in this way, please check the appropriate box.
No I do not wish to have my telephone number and/or address published for any reason. Please list any other information that you do not want published:
____________________________________________________________________________
Yes You may use my telephone number and address in published lists. This includes the School Directory. Here is my information as I would like it to appear:
Photograph and Interview Release 2020-2021 Academic School Year
I hereby grant consent to use and release to the Catholic Archdiocese of Denver and St. Mary Catholic School the use of my name and likeness and that of my child/children, whether in still, motion pictures, audio and video tape; my photograph and photos of my child/children and/or reproductions of me and my child/children including our voice (which includes commentary, remarks, and/or recordings); our features with or without our names, for any promotional purposes involving the Archdiocese and/or St. Mary Catholic School, for news and/or feature stories in the Denver Catholic, El Pueblo Catolico, or other media (which includes Internet, print, radio, television) or for other purposes whatsoever, except for the endorsement of any commercial products.
These items may be used without limitation or reservation of any fee.
Minors cannot consent to media interview or waive their privacy right. These decisions must be made by the parent/guardian; therefore, this release form must be signed by parent/guardain when the individual is a minor.
Parent/Guardian Information
_____________________________________ Print Parent’s/Guardian’s Name _____________________________________ Parent’s/Guardian’s Address _____________________________________ City State Zip Code _____________________________________ Home, Cell and/or Work Phone Numbers
Child/Children Information
_____________________________________ Print Child’s Name Grade
_____________________________________ Print Child’s Name Grade
_____________________________________ Print Child’s Name Grade
____________________________________ Print Child’s Name Grade
No, I do not want my child/children photographed and/or interviewed for any reason.
Yes, I do give permission for my child/children to be photographed and/or interviewed.
_____________________________________ Parent/Guardian Signature
_____________________________________ Date
No, I do not want my child/children photographed and/or interviewed except for the school yearbook or within the school.
___________________________________________________ Mother's Name
____________________________________________________ Mother's Street Address
____________________________________________________ Mother's/Guardian's City, State & Zip Code Mother's/Guardians Phone #
_________________________________________________ Father's/Guardian's Name
_________________________________________________ Father's/Guardian's Address
_________________________________________________ Father's/Guardian's City, State & Zip Code Father's/Guardian's Phone #
St. Mary Catholic School Emergency Card
Academic School Year: 2020-2021
Student’s Name_________________________________________ Date of Birth ______________________ Street Address ___________________________________________City _______________ Zip________ Male Female Home Phone _________________ If Catholic, Parish Affiliation __________________
Parent/Guardian Information
Address Work Phone
__________________________________ _________________ _________________ _________________ _______________________
__________________________________ _________________ _________________ _________________ _______________________
__________________________________ _________________ _________________ _________________ _______________________
Specific Persons NOT Authorized to Pick-Up Child Last Name First Name Relationship ______________________________________ _________________________________________ ________________________________ ______________________________________ _________________________________________ ________________________________
Student Records Update I understand that I must keep my child’s records up-to-date with current information.
_______________________________________
______________________
I give the school my permission to take my child to a hospital to receive emergency treatment. I hereby consent to any x-ray examination, medical or surgical diagnosis or treatment, and hospital care to be rendered to my child under the general or direct supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act. I also consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to my child by a dentist under the provisions of the Dental Practice Act. I authorize the medical facility to release my child into the custody of a school representative should hospital care no longer be needed. I understand that this is only in an extreme emergency and when the parent or legal guardian cannot be reached. I understand that I am responsible for any expenses incurred by the medical and/or dental diagnosis or treatment. I agree to pick up my child if he/she is sick or injured. If I cannot be reached, the above emergency contacts can be called to pick up my child.
__________________________ ________________
In case of an Emergency or Illness, who should be contacted first? _____________________________ __________________________ ________________ ___________________________ ________________
Mother/GuardianFather/Guardian Home Phone Home Phone
____________________________ _____________ City, State, Zip Cell Phone ___________________________________________ Employer ___________________________________________ Work Address, City, State, Zip
Name Home Phone Work Phone Cell Phone Relationship
Emergency Contact Authorized to Pick-Up ChildUnder no circumstances will your child be released to anyone not known to the school without verbal permission from a parent or legal guardian.
Photo ID may be required.
Medical Information Heath Conditions (such as asthma, diabetes, allergies, epilepsy, heart disease, contacts, etc.) _______________________________________________________________________________________ Current Medications: _____________________________________________________________________ ________________________________ ___________________________________ ________________ Child’s Physician Address, City, State, Zip Phone ______________________________________ __________________________________________ __________________ Child’s Dentist Address, City, State, Zip Phone ______________________________________ __________________________________________ ___________________ Hospital of Choice Address, City, State, Zip Phone
Medical Authorization
____________________________ _______________ Address Work Phone
_________________________________________________________________________ Work Address, City, State Zip
__________________________________________________________________________ Employer
____________________________ _______________ City, State, Zip Cell Phone
Parent Signature Date
St. Mary Catholic School Emergency Card
Academic School Year: 2020-2021
Student’s Name Date of Birth
Street Address Zip
Male Female Home Phone
City
If Catholic, Parish Affiliation
Parent/Guardian Information
In case of an Emergency or Illness, who should be contacted first?
Father/Guardian Home Phone Mother/Guardian Home Phone
Address Work Phone Address
City, State, Zip Cell Phone
Employer
Work Address, City, State, Zip Work Address, City, State Zip
Emergency Contact Authorized to Pick-Up Child Under no circumstances will your child be released to anyone not known to the school without verbal permission from a parent or legal guardian.
Photo ID may be required.
Name Home Phone Work Phone Cell Phone Relationship
Specific Persons NOT Authorized to Pick-Up Child Last Name First Name Relationship
Medical Information
Heath Conditions (such as asthma, diabetes, allergies, epilepsy, heart disease, contacts, etc.)
Current Medications:
Child’s Physician Address, City, State, Zip Phone
Child’s Dentist Address, City, State, Zip Phone
Hospital of Choice Address, City, State, Zip Phone
Medical Authorization
Student Records Update I understand that I must keep my child’s records up-to-date with current information.
I give the school my permission to take my child to a hospital to receive emergency treatment. I hereby consent to any x-ray examination, medical or surgical diagnosis or treatment, and hospital care to be rendered to my child under the general or direct supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act. I also consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to my child by a dentist under the provisions of the Dental Practice Act. I authorize the medical facility to release my child into the custody of a school representative should hospital care no longer be needed. I understand that this is only in an extreme emergency and when the parent or legal guardian cannot be reached. I understand that I am responsible for any expenses incurred by the medical and/or dental diagnosis or treatment. I agree to pick up my child if he/she is sick or injured. If I cannot be reached, the above emergency contacts can be called to pick up my child.
City, State, Zip Cell Phone
Employer
Parent Signature Date
_____________________________ ________________
________________ Work Phone
___________________________________________
_
St. Mary Catholic School Emergency Card
Academic School Year: 2020-2021
Student’s Name Street Address
Date of Birth City Zip
Male Female Home Phone If Catholic, Parish Affiliation
Parent/Guardian Information
In case of an Emergency or Illness, who should be contacted first?
Father/Guardian Home Phone Mother/Guardian Home Phone
Address Work Phone Address Work Phone
City, State, Zip Cell Phone
Employer
Work Address, City, State, Zip Work Address, City, State Zip
Emergency Contact Authorized to Pick-Up Child Under no circumstances will your child be released to anyone not known to the school without verbal permission from a parent or legal guardian.
Photo ID may be required.
Name Home Phone Work Phone Cell Phone Relationship
Specific Persons NOT Authorized to Pick-Up ChildLast Name First Name Relationship
Medical Information
Heath Conditions (such as asthma, diabetes, allergies, epilepsy, heart disease, contacts, etc.)
Current Medications:
Child’s Physician Address, City, State, Zip Phone
Child’s Dentist Address, City, State, Zip Phone
Hospital of Choice Address, City, State, Zip Phone Medical Authorization
Student Records Update I understand that I must keep my child’s records up-to-date with current information.
I give the school my permission to take my child to a hospital to receive emergency treatment. I hereby consent to any x-ray examination, medical or surgical diagnosis or treatment, and hospital care to be rendered to my child under the general or direct supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act. I also consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to my child by a dentist under the provisions of the Dental Practice Act. I authorize the medical facility to release my child into the custody of a school representative should hospital care no longer be needed. I understand that this is only in an extreme emergency and when the parent or legal guardian cannot be reached. I understand that I am responsible for any expenses incurred by the medical and/or dental diagnosis or treatment. I agree to pick up my child if he/she is sick or injured. If I cannot be reached, the above emergency contacts can be called to pick up my child.
City, State, Zip Cell Phone
Employer
Parent Signature Date
_
St. Mary Catholic School Emergency Card
Academic School Year: 2020-2021
Student’s Name Date of Birth
Street Address Zip
Male Female Home Phone
CityIf Catholic, Parish Affiliation
Parent/Guardian Information
In case of an Emergency or Illness, who should be contacted first?
Father/Guardian Home Phone Mother/Guardian Home Phone
Address Work Phone Address Work Phone
City, State, Zip Cell Phone
Employer
Work Address, City, State, Zip Work Address, City, State Zip
Emergency Contact Authorized to Pick-Up Child Under no circumstances will your child be released to anyone not known to the school without verbal permission from a parent or legal guardian.
Photo ID may be required.
Name Home Phone Work Phone Cell Phone Relationship
Specific Persons NOT Authorized to Pick-Up Child Last Name First Name Relationship
Medical Information
Heath Conditions (such as asthma, diabetes, allergies, epilepsy, heart disease, contacts, etc.)
Current Medications:
Child’s Physician Address, City, State, Zip Phone
Child’s Dentist Address, City, State, Zip Phone
Hospital of Choice Address, City, State, Zip Phone
Medical Authorization
Student Records Update I understand that I must keep my child’s records up-to-date with current information.
I give the school my permission to take my child to a hospital to receive emergency treatment. I hereby consent to any x-ray examination, medical or surgical diagnosis or treatment, and hospital care to be rendered to my child under the general or direct supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act. I also consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to my child by a dentist under the provisions of the Dental Practice Act. I authorize the medical facility to release my child into the custody of a school representative should hospital care no longer be needed. I understand that this is only in an extreme emergency and when the parent or legal guardian cannot be reached. I understand that I am responsible for any expenses incurred by the medical and/or dental diagnosis or treatment. I agree to pick up my child if he/she is sick or injured. If I cannot be reached, the above emergency contacts can be called to pick up my child.
City, State, Zip Cell Phone
Employer
Parent Signature Date
PLEASE KEEP THIS FIRST PAGE FOR YOUR INFORMATION
St. Mary Catholic School 2020 - 2021 School Year
ST. MARY CATHOLIC SCHOOL CARE PROGRAM
HOURS OF OPERATION: Morning -----------7:00 AM – 8:00 AM NO AFTERNOON CARE ON Noon Dismissal DAYS Afternoon----------3:30 PM – 5:30 PM
Morning Care will be held in the school library. Aftern oon Care will be in classroom 2 & 3 in the parish center until 4:30pm. After 4:30pm, after Care will be in the school library. In case you need to call between 4:00pm and 4:30pm the number is 970-353-8100, then press 252; and after 4:30pm the number is 970-353-8100, then press 207.
COST FOR EXTENDED CARE:
Rates are based on hourly or half hour fees. Rates are $6.00/ hour or $3.00/half hour/child.
****THERE IS A $10.00 LATE FEE FOR C HILDREN PICKED UP AFTER 5:30 PM.
BILLING INFORMATION: Billing for St. Mary Care Program will be sent out every two weeks in the Wednesday communication envelope. Please return your payment in the Wednesday envelope to the school office. The payment must be paid no later than Friday of the mailing week. A LATE FEE OF $5.00 WILL BE ASSESSED FOR PAYMENT AFTER FRIDAY OF THE BILLING CYCLE.
SNACK: An afternoon snack will be provided.
ACTIVITIES: Daily activities include snack, reading, homework time, table games and outside activities.
REGISTRATION: Before a child can attend this program, an application must be completed in its entirety.
OTHER QUESTIONS: Please call Terri Tafoya, Program Director at 970-353-8100, extension 227.
St. Mary Catholic School ST. MARY CARE PROGRAM
SMCP APPLICATION FOR ENROLLMENT 2020 - 2021 SCHOOL YEAR
Student’s Name ___________________________ ______________________ Grade Birthdate Student Name
Student’s Name ___________________________ ______________________ Grade Birthdate Student Name
Student’s Name ___________________________ ______________________ Student Name Grade Birthdate
Student’s Name ___________________________________________________________________________ Student Name Grade Birthdate
Father/Guardian __________________________________________________
Address / Zip Code _______________________________________________________________________
Child/Children live(s) with: ________________________________________
According to Colorado State Law only the people listed below will be allowed to pick up your child/children unless otherwise directed by the parent by way of verbal notice. Photo ID may be requested.
The people listed below are emergency contacts authorized to pick up my children
1. ___________________________ ______________ _____________ ______________ ______________
2.
3.
Relationship Home Phone
Please indicate below if there is any person(s) NOT ALLOWED to pick up your child.
_________________________________________________________________________________________
_________________________________________________________________________________________
Name
___________________________Name
___________________________Name
______________ _____________ ______________ ______________
______________ _____________ ______________ ______________
Work Phone Cell Phone
Relationship
Relationship
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Mother/Guardian __________________________________________________________
Address / Zip Code _______________________________________________________________________
SIGNATURE____________________________________DATE__________________________
AUTHORIZATION FOR EMERGENCY MEDICAL CARE:
I, _________________________________ hereby give my permission for St. Mary Catholic School Staff to call for medical or make surgical decisions for my child/children ______________________ ____________________, _______________________, or ______________________ should an emergency arise. It is understood that a conscientious effort will be made to locate me before emergency action or decision will be taken, but if this is not possible the expenses of emergency medical treatment or care will be accepted and paid by me.
* PERMISSION FOR PARTICIPATION IN ACTIVITIES:I give permission for my child/children to participate in all program activities except for the following:
*
PERMISSION TO USE: Sunscreen Yes No Bug Spray Yes No*
MEDIA USE: My child/children may participate in the use of media as listed in the contract and any provider deemed appropriate computer/video games. There will be no higher rating than E/PG for any of these items. Yes No Except following: _____________________________________________
Parent/Guardian _________________________________ Date ______________________________
_____________________________________________________________________________________
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St. Mary Catholic School ST. MARY CARE PROGRAM ANNUAL AUTHORIZATION FORM
CARE PAGE 2 OF 3
*
ST. MARY CATHOLIC SCHOOL 2351 22nd Avenue, Greeley, CO 80631 • 970-353-8100 • Fax 970-353-8700
"Thechild grew and became strong,filled with wisdom; and the favor of God was upon him" (Lk 2:40)
Before/After Care Financial
Contract 2020- 2021 School Year
Parent/Guardian Signature Date
Family Name _________________________________
St. Mary Catholic School offers a Before and After Care program for the convenience of our students and parents. Before Care is available from 7:00 am to 8:00am and the After Care program is available from 3:30pm to 5:30pm. The current cost of the program is $6.00 per hour per child prorated. There is also a late charge of $10 for children picked up after 5:30pm. Care is billed bi-weekly and due upon receipt of invoice.
By signing this form you acknowledge that it is your responsibility to pay the Care bill on a timely basis. If for any reason you owe money for Care at the end of the school year, St. Mary will actively collect the debt up to and including turning your account over to collections.
CARE PAGE 3 OF 3
The family out-of-parish affiliation form is used to determine if a family/parent/guardian qualifies for the affiliated tuition rate as a registered member of their parish. On an annual
basis, the family out-of-parish affiliation form must be submitted by the family and signed by their pastor in order for the family/parent/guardian to receive the affiliated tuition rate.
Parish affiliation is defined as families who are registered members of Archdiocese of Denver parishes and whose children are enrolled in an archdiocesan elementary school not in
their parish of membership for Kindergarten or a higher grade, or one of the two archdiocesan-operated high schools. These families are eligible to receive the affiliated Catholic tui-
tion rate if they meet the following criteria:
1) The family has been registered in the parish for at least six (6) months.
2) The family verifiably contributes, according to their means, on a regular basis to the financial support of the parish.
3) The family attends weekend Mass regularly and is involved in the activities, organizations or programs at the parish.
Name
Address
Phone
Student Name Grade
Student Name Grade
Student Name Grade
Student Name Grade
I/We have read and understand the parish affiliation policy and criteria used to determine parish affiliation and qualifying for the affiliated tuition rate. I/We understand that the infor-
mation provided is subject to verification. If it is determined that I/we do not qualify, I/we will be notified and agree that the tuition rate will be increased to the unaffiliated rate for the
school year. I/We understand that all paperwork and associated confirmation of parish affiliation must be on file with the school on or before September 16.
Parent/Guardian Signature ___________________________________________________________________________ Date ______________________________________
This family is eligible to receive the affiliated tuition rate at St. Mary Catholic School.
Pastor Sign ature __________________________________________ Date: ________________________________
To be completed by Parish Office on an annual basis
To be completed by Family/Parent/Guardian on an annual basis
I/We are registered parishioners at ___________________________________________________________ located in _______________________________________________.
If approved by the pastor, students in grades
Kindergarten—12 qualify as Out-of-Parish
Affiliated Students (OPAS)
FAMILY OUT-OF-PARISH AFFILIATION
St. Mary Catholic School
2020 - 2021 Academic School Year
2351 22nd Ave. Greeley, CO 80631 Fax # 970-353-8700
It is the responsibility of the local-level principal, pastor and business manager to determine the internal process to track and validate “in-parish” affiliation. The Family Out-of-Parish
Affiliation form is used to track and validate out-of-parish family affiliation only. AoDCS, OCS February 10, 2014
This family is not eligible to receive the affiliated tuition rate at St. Mary Catholic School.
Comments ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ST. MARY PARISH AFFILIATION CONFIRMATION
St. Mary Catholic School 2020 - 2021 Academic School Year
School: St. Mary Catholic School, 2351 22nd Ave, Greeley, CO 80631 (970) 353-8100
FAX: (970) 353-8700
To be completed by Family/Parent/Guardian on an annual basis
Student Name(s): Grade :
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
4. ________________________________________________
______________
______________
______________
______________
Parents’ or Guardians’ Information:
Name: ________________________________________________________________Address: ______________________________________________________________ Telephone: ___________________________
To be completed by Parish Office on an annual basis
This family is eligible to receive the affiliated tuition rate at St. Mary Catholic School.
This family is not eligible to receive the affiliated tuition rate at St. Mary Catholic School.
____________________________ Pastor’s Signature Date