Heart Of Mary

Apply To Heart of Mary

Application for Enrollment

2022 - 2023

Date Of Application

Grade Entering

Student Information/Data

First Name

Middle Name

Last Name

Student's Address

City

State

Zip Code

Date Of Birth

Gender

Race/National Origin (Select an option)

Religion

Present Parish/Church

Parent/Guardian Information

Mother/Stepmother/Guardian

First Name

Last Name

Address

City

State

Zip Code

Home Phone

Cell Phone

May we text you at this number? Yes No

Employer

Work Phone

Father/Stepther/Guardian

First Name

Last Name

Address

City

State

Zip Code

Home Phone

Cell Phone

May we text you at this number? Yes No

Employer

Work Phone

With whom does the student live?

Student Sacramental History Information

Baptismal Date

Parish

First Reconciliation Date

Parish

First Communion Date

Parish

Education History

Public School Zone (the public school the student would attend)

Last School Attended

Grade

School Address

Has the student been on probation, suspended, dismissed or expelled from any school?
(If yes, attach documentation)

Yes No

Has your child ever been retained in any grade?

Yes No

If so, what grade?

Reason for retention?

Has your child every been diagnosed with any of the following?

Learning Disability Attention Deficit/Hyperactivity Disorder None

Has your child been prescribed medication for any of the disorders?
(If yes, please name below)

Yes No

Medical Information

Physician

Phone

Insurance Carrier

Policy Number

Preferred Hospital

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

Yes No

SPECIFIC MEDICAL INFORMATION: The school will take reasonable care to see that the following information will be held in confidence:

MEDICATIONS: My child is taking medication at present. He/She is capable of administering this medication as required. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows:

Allergic Reactions (medications, foods, plants, insects, etc.):

***If your child is allergic to certain foods and will require alternative choices in the cafeteria, you must provide documentation from your child's doctor.

Additional special medical conditions of my child: (Physician Documentation Attached)

Legacy Information

Are you an Alumni of HOM School?

Yes No

Year graduated

Are any family members alumni of HOM? If so, please name.

Emergency Contacts

Name

Relationship

Phone

Name

Relationship

Phone

Does your child/children receive after-school care?

Yes No

If so, what facility?

Phone

Person(s) responsible for picking up your child/children

Relationship to child/children

Who many NOT pick up your child/children from school?

Parent "Permission" Requirement

During the school year, staff of Heart of Mary Catholic and media representatives may want to interviews, photograph or videotape your child for use in publications, television reports, social media and websites. The photographs may be of groups of students or individuals, and the students' names may be used.

Please mark one:

I give permission for my child to be photographed and/or interviewed, and permission to have my child's name used.

Yes No

I do not want my child photographed or interviewed and do not want his or her name used.

Yes No

Use of the internet as guided by the school usage policy. I understand any violation of this policy by the child may result in appropriate actions.

Yes No

I attest that all information provided above is accurate. Should information be found fraudulent it may jeopardize my child’s enrollment at this school.

I certify that all responses given on this application are true and complete. I understand that the falsification and/or omission of fact may result in denial of admission or removal of student from Heart of Mary Catholic.

Parent/Guardian Signature

Date

Admission is open to all students regardless of race, religion, national or ethnic origin.

Attach Documents

Maximum size of attachments is 10MB

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Please update the missing fields to continue.

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HEART OF MARY SCHOOL

310 Sengstak St. | Mobile, AL 36603

251-432-5270

office@mphom.org

Heart of Mary School admits students of any race, color, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.

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Apply To Heart of Mary

Application for Enrollment

2022 - 2023

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HEART OF MARY SCHOOL