St. Michael Catholic School
704 St. Michael Lane
Gastonia, NC 28052
704-865-4382
www.SMSGASTONIA.com
Sschool792@aol.com
Pre-K Admission Application
Application Date __________
Please complete this application and return it to St. Michael’s School with the following:
* $25 non-refundable application and testing fee (for new families) to initiate the
admissions process. (Make checks payable to St. Michael School)
* Copy of the birth certificate
* Copy of the student’s baptismal certificate if student is Catholic
* Proof of Physical Exam and Immunization (Health form enclosed)
* Parish Participation Voucher if applicable (enclosed)
FAMILY INFORMATION
Father’s Name (or Legal Guardian)_______________________________________
Address __________________________________________________________
City_______________________________ State ___________Zip Code __________
Home Telephone____________________Cell Phone Number _________________
Work Telephone____________________Other Phone Number________________
Email Address______________________________________________________
Occupation _______________________Employer _________________________
Religion _________________________ Name of Church ____________________
City_______________________________ State _________Zip Code __________
Mother’s Name (or Legal Guardian)______________________________________
Address __________________________________________________________
City_______________________________ State _______ Zip Code __________
Home Telephone___________________Cell Phone Number ________________
Work Telephone___________________Other Phone Number_______________
Email Address____________________________________________________
Occupation _______________________Employer ________________________
Religion _________________________Name of Church __________________
City_______________________________ State _______Zip Code __________
Student Information
Full Name_________________________ Preferred Name____________________
Male______Female_______ Date of Birth________________________________
Social Security Number______-_____-______
Religion ______________________________
Has student been baptized? Yes _____ No _____
Did Child Attend Pre-School/Day Care ? If yes, School Attended________________
List Siblings of Applicant
Name ____________________Birthdate _______ Grade ___ School ______________
Name ___________________ Birthdate _______ Grade ___ School ______________
Name ___________________ Birthdate _______ Grade ___ School ______________
Name ___________________ Birthdate _______ Grade ___ School ______________
Name ___________________ Birthdate _______ Grade ___ School ______________
Name ___________________ Birthdate _______ Grade ___ School ______________
Please give any information concerning your child that will be helpful in his/her experience in
group settings (such as play, eating & sleeping habits, special fears, special likes or dislikes)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
If you can’t pick up your child, please give the persons to whom the child can be released to:
Name ________________ Relationship _______________________
Home Phone _________ _____ Other Phone____________________________
Name ________________ Relationship _______________________
Home Phone _________ _____ Other Phone____________________________
Medical Information
Does your child have any known allergies: Yes No______
Explain:____________________________________________________________
Insurance Carrier______________________ Policy #_______________
Emergency Information
Name of child’s doctor_____________________ Phone______________________
Address___________________________________________________________
Name of child’s dentist ________ Phone__________________________
Address___________________________________________________________
Hospital preference _______ Phone__________________________
In the event of an emergency if neither father/mother/or guardian can’t be reached, please call:
Name Relationship Home Phone Office Phone_________
Name Relationship Home Phone Office Phone_________
I agree that the operator may authorize the physician of his/her choice to provide emergency care
in the event that neither I, nor the family physician can be contacted immediately.
_______________________________________ ____________________________
Signature of Parent/Guardian Date
I, as the operator, do agree to provide transportation to an appropriate medical resource in the
event of emergency. In an emergency situation, the other children in the facility will be
supervised by a responsible adult. I will not administer any drug or medication without specific
instructions from the physician or the child’s parent, guardian or full-time custodian. Provisions
will be made for adequate and appropriate rest and outdoor play.
________________________________________ ____________________________
Signature of Operator Date
Please state the reasons for wishing to enroll your child(ren) in St. Michael Catholic School
___________________________________________________________________
___________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_______________________________ __________________________________
Signature of Parent or Legal Guardian Printed Name of Parent or Legal Guardian
Date: ___________________________
How were you refereed to Saint Michael School: (Please circle one)
Advertisement Church SMS Family Other _______________
If referred by a Saint Michael School Family, please list family primarily responsible for
referring you: _______________________________________________________