School Yearrequired

Student Information

First Namerequired

Middle Name

Last Namerequired

Nickname

Genderrequired

Birthdaterequired (mm/dd/yyyy)

Grade To Attendrequired

Last School/Program Attendedrequired

Religionrequired

Race*

(check all that apply)

American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White

Ethnicityrequired

This student lives with*

(check all that apply)

Both Parents Mother Father Step-Parent Host-Parents Other

Does this student have any special needs that we should be aware of to support their learning?*

Yes No

Special Learning Needs

If eligible, will this student require busing?*

Yes No

Adult/Guardian Information

Prefix

First Namerequired

Middle Name

Last Namerequired

Suffix

Genderrequired

Address 1required

Address 2

Cityrequired

Staterequired

Ziprequired (ex. 06108 or 06108-0809)

Household Phone

Work Phone

Mobile Phone

I would like to opt-in to receive text messaging alerts

Yes No

I would like to opt-in to receive voice messaging alerts

Yes No

Home Email

Work Email

Indicate which email address you would like used for electronic communication

Home Work

Relationship to Studentrequired

I am Legal Guardian for Studentrequired

Occupation

Employer

Do you wish to add additional adult/guardian information for students listed above?*

Yes No

Adult/Guardian Information #2

Prefix

First Namerequired

Middle Name

Last Namerequired

Suffix

Genderrequired

Same Address as adult #1?

Yes No

Address 1required

Address 2

Cityrequired

Staterequired

Ziprequired (ex. 06108 or 06108-0809)

Household Phone

Work Phone

Mobile Phone

I would like to opt-in to receive text messaging alerts

Yes No

I would like to opt-in to receive voice messaging alerts

Yes No

Home Email

Work Email

Indicate which email address you would like used for electronic communication

Home Work

Occupation

Employer

Potential Host Parent Information #1

Prefix

First Name

Middle Name

Last Name

Suffix

Gender

Same Address as adult #1?

Yes No

Address 1

Address 2

City

State

Zip (ex. 06108 or 06108-0809)

Household Phone

Work Phone

Mobile Phone

I would like to opt-in to receive text messaging alerts

Yes No

I would like to opt-in to receive voice messaging alerts

Yes No

Home Email

Work Email

Indicate which email address you would like used for electronic communication

Home Work

Employer

Do you wish to add additional potential host parent information?

Yes No

Potential Host Parent Information #2

Prefix

First Name

Middle Name

Last Name

Suffix

Gender

Same Address as Host Parent #1?

Yes No

Address 1

Address 2

City

State

Zip (ex. 06108 or 06108-0809)

Household Phone

Work Phone

Mobile Phone

I would like to opt-in to receive text messaging alerts

Yes No

I would like to opt-in to receive voice messaging alerts

Yes No

Home Email

Work Email

Indicate which email address you would like used for electronic communication

Home Work

Occupation

Employer

Additional Information

Were you referred to Rochester Catholic Schools?*

Yes No

Name of person(s) that referred you:

Email of person that referred you:

Address of person that referred you:

I understand that transportation is the responsibility of the parent(s)/guardian(s). A school representative will be contacting you regarding the form you will need to complete.

How did you hear about us?

Check all that Apply

Internet Search Family/Friend Referral Advertisement Open House Rochester Catholic Parish Direct Mail Other

Additional Comments

Please communicate any additional comments

Registration

The registration fee is a one-time, non-refundable deposit of $125 per student.

After hitting the submit button you will be directed to a payment page where you can make your one time registration payment.

$125