Parent Admission Questionnaire

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	The following information must be submitted prior to the admissions interview.

1.	Student's Current Grade Level
	Student's Current Grade Level Grade 9 Grade 10 Grade 11 Grade 12

2.	Student's Current School

3.	Reason for Student Wanting to Leave Current School and Enter CHS

4.	Academic year for which student is seeking admission
	Academic year for which student is seeking admission 2017-2018 2018-2019

5.	Grade Level for which student is seeking admission
	Grade Level for which student is seeking admission Grade 9 Grade 10 Grade 11 Grade 12

6.	Semester for which student is seeking admission
	Semester for which student is seeking admission 1st 2nd

	Student Information:

7.	Student Name

8.	Address

9.	City

10.	State

11.	Zip

12.	Home Phone (with area code)

13.	Date of Birth
	mm/dd/yyyy

14.	Sex
	Sex Male Female

15.	Place of Birth

16.	Citizenship

17.	Language spoken in the home

18.	Is applicant fluent in English?
	Is applicant fluent in English? Yes No

19.	Religion

20.	Parish/Church

	Parent/Guardian Information Student Resides With:

21.	Father/Residing Male's Name

22.	Work/Daytime Phone (with area code)

23.	Occupation

24.	Employer (N/A if not employed)

25.	Employer Address (N/A if not employed)

26.	Employer Phone Number (N/A if not employed)

27.	Mother/Residing Female's Name

28.	Work/Daytime Phone (with area code)

29.	Occupation

30.	Employer (N/A if not employed)

31.	Employer Address (N/A if not employed)

32.	Employer Phone Number (N/A if not employed)

	If non-custodial parent is involved in educational matters, please provide their information below:

33.	Name

34.	Relationship

35.	Phone Number (with area code)

	Sibling Information:

36.	Sibling Name

37.	School:

38.	Grade/Year of Graduation

39.	CHS Alumnus?
	CHS Alumnus? Yes No

40.	Sibling Name

41.	School

42.	Grade/Year of Graduation

43.	CHS Alumnus?
	CHS Alumnus? Yes No

	History of Information on Schools Attended by Applicant:

44.	School Name

45.	Location

46.	Dates Attended

Grade Levels

Grade 9

Grade 10

Grade 11

Grade 12

	Additional School Information, if applicable

48.	School Name

49.	Location

50.	Dates Attended

51.	Grade Levels

52.	School Name

53.	Location

54.	Dates Attended

55.	Grade Levels

	Character References:

56.	Name of current school official

57.	Title

58.	Phone Number (with area code)

59.	Name of non-relative reference

60.	Relationship

61.	Phone Number (with area code)

	Discipline History:

62.	Please describe fully any discipline incidents in which this student has been involved in the past two years:

	Medical/Learning Issues:

63.	Does the applicant have any medical or learning issues that may impact their education?
	Does the applicant have any medical or learning issues that may impact their education? Yes No

64.	Does this student currently have a McKay Scholarship?
	Does this student currently have a McKay Scholarship? Yes No

65.	Does this student have a current Individualized Education Plan (IEP), a 504 Plan, or participate in an Exceptional Student Education (ESE) program?
	Does this student have a current Individualized Education Plan (IEP), a 504 Plan, or participate in an Exceptional Student Education (ESE) program? Yes No

	A student may qualify for State sponsored McKay Scholarship at CHS if transferring a current McKay, or if they have a current IEP and are transferring from a public school.

66.	Does this student have a current (within 3 years) Psycho-educational Evaluation?
	Does this student have a current (within 3 years) Psycho-educational Evaluation? Yes No

67.	If you answered "YES" to any of the above, please explain:


Parental Cooperation Statement:
I wish for my child to be considered for admission to Pensacola Catholic High School.
I understand that the application fee is non-refundable, and acknowledge the financial responsibilities including tuition, books, and additional fees associated with my child's enrollment if accepted.
I certify that the information provided on this form is true and accurate. I verify that I have legal permission to pursue admission to Pensacola Catholic High School.

68.	Name of person making verification:

69.	E-mail address of person making verification

70.	Relationship to Student:
	Relationship to Student: Mother Father Grandparent Legal Guardian

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