Ethnic Code:  ______ Please write the correct number in the space. 1 (white)  2 (American Indian/Native 
Alaskan)  3  (Black/African American)  4  (Haitian)  5  (Hispanic)  6  (Asian)  7  (Native Hawaiian/Pacific
Islander)  8  (Multi Racial)

St. Agnes does not discriminate on the basis of race, religion, color, national and ethnic origin, in the
administration of educational policies, admission policies, scholarship and loan programs, and in the hiring
of school personnel.

Does child have a Special Educational Plan?  IEP ____  504 ____  Date of last physical ______________
Does child have Medical Problems? _______ If yes, please explain:

____________________________________________________________________________________________

____________________________________________________________________________________________________

Sibling's Name(s)                                                            Date of Birth

________________________________                            _________________

________________________________                            _________________

________________________________                            _________________

By registering my child(ren) at St. Agnes, I agree to be responsible for payment of tuition and fees and for
participation in parent service requirements.  (Fair Share Hours, Lunch Monitoring Program)

A fee is required at the time of registration.  This fee is deposited upon acceptance.  Annual
tuition, or the first installment if using FACTS Tuition Management, is due in July.  If a registered student
elects not to attend Saint Agnes School or withdraws at any point during the school year, all tuition
monies received will be forfeited.  An appeal of this policy should be in writing and will be considered
by the school board on a case-by-case basis.

I understand that admission to St. Agnes School is conditional upon completion of tuition payment and
all other financial obligations to previous Catholic schools.  I agree to support and abide by all school
policies and regulations.

I agree to allow my name, address, and telephone number to be released to St. Agnes School organizations.**

Signature _____________________________________________ Date ___________________

**Those wishing not to have their name, etc. released must submit written notification to the school office
    by the first day of school.

Please list reasons why you are choosing St. Agnes School for your child.