Online Application for Nursery Program

Dear New Families,

Welcome to Holy Angels! It is our hope that your child’s enrollment here will be a wonderful, faith-filled experience. Submittance of this application indicates that you have read and will comply with these important policies.

1. All school and health records, including documentation of immunization must be sent to the school. No student will be able to attend classes on the first day of school without this documentation.

2. All students are on probation for the first 60 days of school. This is done to ensure placement at Holy Angels is mutually acceptable to all.

3. Tuition is to be paid according to schedule. If there is any unforeseen situation that may arise, it is the parent’s responsibility to contact the Business Office immediately.

Student Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Middle Name (if no Middle Name, type "None" REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Gender REQUIRED Male Female Please fill out this field.

Date of Birth REQUIRED Please fill out this field. Please enter an integer (number).

Birthplace City, State REQUIRED Please fill out this field. Please enter valid data.

Home Phone Number REQUIRED Please fill out this field. Please enter valid data.

Student Lives with REQUIRED Please fill out this field.

Other (please specify) Please enter valid data.

Public School District in which the student resides REQUIRED Please fill out this field.

Other District (please specify) Please enter valid data.

Home Parish (parish that you are registered with/attend) REQUIRED Please fill out this field. Please enter valid data.

Student's Religion REQUIRED Please fill out this field. Please enter valid data.

If the student is Catholic, please complete the following:

Baptism - If not applicable, type "N/A"

Church (please include City, State) REQUIRED Please fill out this field. Please enter valid data.

Baptismal Date Please enter valid data.

Ethnic Background of Student: (this information is used to complete the New York State Educational Data Systems report that all public and nonpublic schools are required to submit). REQUIRED American Indian/Native Alaskan Asian Black/African American Hispanic or Latino Native Hawaiian/Pacific Islander White Multi-Racial All Others Please fill out this field.

What is the Students Race? REQUIRED American Indian/Native Alaskan Black/African American White Asian Native Hawaiian/Pacific Islander Please fill out this field.

Physician Name REQUIRED Please fill out this field. Please enter valid data.

Physician Phone Number REQUIRED Please fill out this field. Please enter valid data.

Dentist Name REQUIRED Please fill out this field. Please enter valid data.

Dentist Phone Number REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact (Please include three (3))

Emergency Contact 1

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Home Phone REQUIRED Please fill out this field. Please enter valid data.

Work Phone REQUIRED Please fill out this field. Please enter valid data.

Cell Phone REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact 2

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Home Phone REQUIRED Please fill out this field. Please enter valid data.

Work Phone REQUIRED Please fill out this field. Please enter valid data.

Cell Phone REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact 3

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Home Phone REQUIRED Please fill out this field. Please enter valid data.

Work Phone REQUIRED Please fill out this field. Please enter valid data.

Cell Phone REQUIRED Please fill out this field. Please enter valid data.

Family Background: Mother Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Maiden Name REQUIRED Please fill out this field. Please enter valid data.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Home Address (if different) Please enter valid data.

Religion Please enter valid data.

Country of Birth Please enter valid data.

Date of Entry Into USA Please enter valid data.

Education Completed Please enter valid data.

Occupation Please enter valid data.

Employer Please enter valid data.

Employer Address, City Please enter valid data.

Home Phone Please enter valid data.

Work Phone Please enter valid data.

Cell Phone Please enter valid data.

Home Email REQUIRED Please fill out this field. Please enter valid data.

Work Email Please enter valid data.

Family Background: Father Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Maiden Name REQUIRED Please fill out this field. Please enter valid data.

Relationship REQUIRED Please fill out this field. Please enter valid data.

Home Address REQUIRED Please fill out this field. Please enter valid data.

Religion Please enter valid data.

Country of Birth Please enter valid data.

Date of Entry into USA Please enter valid data.

Education Completed Please enter valid data.

Occupation Please enter valid data.

Employer Please enter valid data.

Employer Address, City Please enter valid data.

Home Phone Please enter valid data.

Work Phone Please enter valid data.

Cell Phone Please enter valid data.

Home Email REQUIRED Please fill out this field. Please enter valid data.

Work Email Please enter valid data.

Parent/s Marital Status REQUIRED Please fill out this field.

Children live with REQUIRED Please fill out this field.

Other (please specify) Please enter valid data.

Note: Both parents have a right to school information regarding the student unless one parent presents a legal document that does not permit this.

Custody: This school assumes that both parents have full parental and residential custody. If this is not the case, it is the responsibility of the parents to provide the school with that portion of the divorce decree or separation agreement that articulates parental and residential custody. Should any changes occur during the year, please inform the school

Please check here if the school should expect a custody agreement Custody Agreement

In case of divorce or separation, please complete the following

Applicant lives with: Mother Father Other

Legal Custody Joint Mother Only Father Only Other

Correspondence should be sent to: Please enter valid data.

If remarried, name of stepfather Please enter valid data.

If remarried, name of stepmother Please enter valid data.

A copy of the Court Order should be on file in the school office if custodial rights are restricted.

Health Information

Is the student currently taking medications? Yes No

If yes, please specify Please enter valid data.

Will the school have to administer medication? Yes No

If yes, please specify Please enter valid data.

Does the medication need to be administered during the school day? Yes No

If yes, when? Please enter valid data.

Provide explanation if your child has any serious health concerns or allergies Please enter valid data.

List any disabilities or special needs your child may have (physical, behavioral, emotional or academic) Please enter valid data.

Indicate any diagnosis evaluations (educational or psychological) that have been administered to your child Please enter valid data.

To be considered for admission, the following documents, including a non-refundable application fee ($100.00), must accompany this application:

1. Completed Student Application
2. Copies of Birth Certificate and Baptismal Certificate
3. Immunization Record: Must be completed and signed by physician before child is accepted.
4. Registered Online with FACTS Management Co. ~ https://online.factsmgt.com/signin/3LZDZ
5. Tuition Agreement: must be completed by each family as part of the registration process and returned to Holy Angels.

Holy Angels Regional School

Patchogue, NY

Online Application for Nursery Program

Holy Angels Regional School