Queen of All Saints Academy
20120 Barnett Rd.
Brooksville, Florida 34601
Tel. (352) 428-0550

or

Queen of All Saints Academy
12546 W. Peoria Ave.
El Mirage, AZ 85335
Tel. (352)428-9858

ENROLLMENT FORM

Re-enrollment Form

Waiver Form

Please print this form as well as the waiver form, and fax or mail them to the Academy.
The deadline for registration is June 28th.

 

Student’s Name __________________________________________________________

SS# ____________________________________________________________________

Entering grade _________________    Date of entry _____________________________

 Home Address___________________________________________________________

City _______________  State ____________Zip _________ Phone (       )____________

Age ___________               Birth date ______________         Gender ________________

Birthplace _____________________________          Race  ________________________

 

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School previously attended:

Name ___________________________  Phone (         )___________________________

Address _________________________________________________   Zip ___________

 

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Father’s name ____________________________________  Birth date ______________

Address ________________________________________________________________

City _________________  State _________ Zip _________ Phone (      )_____________

Mother’s name ___________________________________  Birth date ______________

Address ________________________________________________________________

City _________________  State _________ Zip _________ Phone (      )_____________

 

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Emergency contacts:

1. Name ___________________________________   Relationship _________________

    Address ___________________________________ Phone (      )_________________

2. Name ___________________________________   Relationship _________________

    Address ___________________________________ Phone (      )_________________

3. Physician’s Name _______________________________________________________

    Office Address ______________________________ Phone (       )________________

The Academy may call emergency service in the case that the parents, contacts or physician cannot be contacted:   Yes  _____   No _____

Health conditions or information of which the Academy should be aware:

 

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List the following if the child is Roman Catholic:

Sacrament                                    Date                        Church                               Location

Baptism                                    _______            ______________            __________________

Holy Communion                    _______            ______________            __________________

Confirmation                            _______            ______________            __________________

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Granting of permission:

We give permission for the Academy to administer aspirin or other over-the-counter drugs as deemed necessary:  Yes ______    No ______

We give permission for our child to take part in all school activities, including school sponsored trips away from the school premises and sports (except as specifically listed below), and we agree to relieve the Academy and its employees from any liability in connection with these activities.

Exceptions (if any) :  

Signature of Father __________________________________ Date _________________

Signature of Mother __________________________________Date _________________