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Saint Augustine Elementary

FAMILY ADMISSION QUESTIONNAIRE


(Please use Sibling Questionnaire for additional applicants)
Application Fee of $50.00 per child

Date:___________________________________
School
Applying for Grade _____ Year _____________
Applicant's Name____________________________________________________________________________
Last
First
Middle
Preferred Name__________________________

Phone No. (___)_________________________________

Home Address______________________________________________________________________________
Street
City
State
Zip
__________________________________________________________________________________________
Date of Birth
Age
Place of Birth
Country of Citizenship
__________________________________________________________________________________________
Native Language
Religious Preference
Parish or Church
__________________________________________________________________________________________
Date of Baptism
Date of First Communion
Date of Confirmation
How did you learn about St. Augustine Academy?_________________________________________________
__________________________________________________________________________________________
FAMILY INFORMATION
Are both parents living?_______ Are parents divorced?_______ Separated?_______ Remarried?_______
Does applicant live with both parents?_______ Mother_______ Father_______ Guardian_______
Is he/she adopted?___ Do other adults live at home?___ Names and Role_______________________________
Father's Name__________________________________Home Phone (___)______________________________
Home Address (if diff. from above)_________________________________Religious Preference_____________
Place of work_______________________________________________ Work Phone (___)_________________
Work address______________________________________________ Position or Title___________________
College(s) attended_________________________________________

Degree(s)________________________

Campus: 121 Davis Street, Santa Paula, CA 93060


Mailing Address: P.O. Box 4506, Ventura California 93007
805-672-0411 Fax 805-672-2365
www.SaintAugustineAcademy.com e-mail: StAugAcad@juno.com
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Saint Augustine Elementary


Fathers hobbies or special interests:
(Including musical, dramatic, athletic, computer, crafts, etc.)

Mothers Name__________________________Maiden Name____________Home Phone(_____)


Home Address (if diff. from above)_________________________________Religious Preference
Place of work__________________________________________________ Work Phone (___)
Work address___________________________________________________Position or Title
College(s) attended______________________________________________Degree(s)

Mothers hobbies or special interests:


(Including musical, dramatic, athletic, computer, crafts, etc.)

Names and Ages of Siblings

School Currently Attending

VOLUNTEER WORK:
Please list present and past involvement in diocesan, parish, apostolic or civic groups with which you have donated your
time.

SCHOOL HISTORY
List names of schools applicant has attended. (An official transcript will be necessary before admission.)
If applicant has been home-schooled, please list length of time, grade levels and curricula used.
School
Location
Attendance Dates

Campus: 121 Davis Street, Santa Paula, CA 93060


Mailing Address: P.O. Box 4506, Ventura California 93007
805-672-0411 Fax 805-672-2365
www.SaintAugustineAcademy.com e-mail: StAugAcad@juno.com
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Saint Augustine Elementary


Does the applicant have any diagnosed physical or learning disabilities?_____ If yes, please describe:

Has he/she had academic problems?___ If so, in what areas?


MEDICAL INFORMATION
(A medical examination and certificate signed by the doctor are required before enrollment.)
Does applicant suffer from any specific health conditions that we should be aware of?
Please explain:
Does he/she require any special attention?
Is he/she currently taking any medication?____If so, what kind?
Has applicant ever had an operation?___ If so, what and at what age?
Has he/she ever had a serious injury?____If so, what and at what age?
Has applicant stayed home from school repeatedly or for long periods due to illness?
Please explain:
Has applicant ever received special attention or evaluation from a psychologist, therapist or counselor?
If so, please list date, name and address of consultants and describe situation briefly.

PARENT QUESTIONNAIRE
In order for us to get to know you and your child better, please answer the following questions:
What would you say are your child's main assets, qualities, strengths and talents (academically, socially, physically,
and/or morally)?

What do you expect from us and for your child(ren) by sending your child(ren) to St. Augustine?

Campus: 121 Davis Street, Santa Paula, CA 93060


Mailing Address: P.O. Box 4506, Ventura California 93007
805-672-0411 Fax 805-672-2365
www.SaintAugustineAcademy.com e-mail: StAugAcad@juno.com
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Saint Augustine Elementary


What kinds of activities do you enjoy doing together as a family?

What kind of discipline/reward system do you practice at home?

********************************************************************************************
I hereby certify that all information provided on this application and all information given to St. Augustine Academy, is complete and accurate, and I
understand that falsification or omission of information may result in disqualification or dismissal.
Furthermore, I understand that all information submitted to St. Augustine Academy is confidential and that the Director of Admissions may disclose,
for official purposes, any information received from the applicant according to his discretion.

Parents' or guardians' signatures:

Date:

____________________________________________________________________________________________
____________________________________________________________________________________________
Checklist: Requirements for Admission
We must receive the following items to consider your application:
___Completed Application Form
___Copy of Birth Certificate
___Copy of Baptismal Certificate

___ Application and Testing fee of $50.00


___ Copies of any report cards or Standard Tests (Iowa Basic) from
previous schools

___Immunization Records
NOTE: If accepted the registration fee is the first two months tuition in advance.
********************************************************************************************
OFFICE USE ONLY:
Accepted:
Not Accepted:
App. Fee Pd.
Date
Ck.#
Reg. Fee Pd.

Date

Ck#

Comments:

Campus: 121 Davis Street, Santa Paula, CA 93060


Mailing Address: P.O. Box 4506, Ventura California 93007
805-672-0411 Fax 805-672-2365
www.SaintAugustineAcademy.com e-mail: StAugAcad@juno.com
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