Queen of All Saints Academy
20120 Barnett Rd.
Brooksville, Florida 34601
Tel. (352) 799-5044 Fax. (352) 799-6605
or
Queen of All Saints Academy
12546 W. Peoria Ave.
El Mirage, AZ 85335
Please print this form and fax or mail it 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 ______________ Sex ___________________
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 _________________