York Catholic Middle &High School
Student Registration Form
Student Name
*
First Name
Full Middle Name
Last Name
Grade Enrolling:
*
Please Select
7
8
9
10
11
12
School Year Enrolling
*
(Please type school year student will start)
Gender
*
Male
Female
N/A
Student Date of Birth
*
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Month
/
Day
Year
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Student Ethnicity
*
Please Select
White/Caucasian (not Hispanic)
Black/African American (not Hispanic)
American Indian/Native Alaskan
Asian (not Hispanic)
Native Hawaiian/Pacific Islander (not Hispanic)
Multi-Racial (not Hispanic)
Hispanic (any race)
Can put a small description if necessary
School Admitted From:
*
Please Select
Holy Trinity
St. John the Baptist
St. Joseph, York
St. Rose of Lima
Central York School District
Dallastown Area School District
Dover School District
Eastern York School District
Southern School District
Northeastern School District
Red Lion School District
South Eastern School District
Spring Grove School District
West Shore School District
West York School District
York City School District
York Suburban School District
OTHER
School Name
Student's Religion
*
Please Select
Catholic
Non Catholic
No Religious Affiliation
Anglican
Baptist
Bretheren
Buddist
Christian
Eastern Rite Catholic
Episcopal
Fundamental Christian
Greek
Greek Orthodox
Hindu
Islam
Jewish
Jewish/Catholic
Lutheran
Methodist
Mormon
Muslim
Non-Denominational
Orthodox
Other
Pentecostal
Pentecostal/Evangelical
Presbyterian
Protestant
Unknown
Name of Parish or Church
*
Please Select
Non Catholic
Non Parishioner
Holy Infant, York Haven
Holy Trinity, Columbia
Immaculate Conception, York
Immaculate Heart of Mary, Abbottstown
Sacred Heart of Jesus, Spring Grove
Saint John the Baptist, New Freedom
Saint Joseph, Dallastown
Saint Joseph, York
Saint Patrick, York
Saint Peter, Columbia
Saint Rose of Lima, York
Saint Vincent de Paul, Hanover
Other/Parish Not Listed
Sending School District
*
Please Select
Central York SD
Dallastown Area SD
Dover Area SD
Eastern York SD
South Eastern SD
South Western SD
Southern Columbia SD
Southern York County SD
Spring Grove Area SD
West Shore SD
West York Area SD
York City SD
York Suburban SD
Maryland
Northern York Co SD
Red Lion Area SD
Northeastern SD
Other
For busing purposes
Students Primary Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is the student a United States citizen
Yes
No
Parent's Information
Please complete all information
Primary Contact
*
Mother
Father
Guardian
Mother's Name
Mother's Phone Number
-
Area Code
Phone Number
Mother's Address
Same as Students
Mother's Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mother's Email
Mother's Employer
Mother: Check all that Apply
Custody / Legal Guardian
Mail Correspondence
Email Correspondence
Can Pick up Student
Father's Name
Father's Phone Number
-
Area Code
Phone Number
Father's Address
Same as Students
Father's Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Father's Email
Father's Employer
Father: Check all that Apply
Custody / Legal Guardian
Mail Correspondence
Email Correspondence
Can Pick up Student
Is another language besides English spoken at home?
*
No
Yes
If Yes, What Language
Will you be applying for Financial Aid?
*
Yes
No
Not sure
Further Information
Emergency Contact Name
Emergency Home #
Emergency Cell #
Relation to Student
(Grandparent, aunt, friend, etc.)
Sibling 1
Grade
Sibling 2
Grade
Sibling 3
Grade
Parent and Guardian volunteerism is needed in the following areas. Please check those you are interested in assisting:
Events & Fundraising
Cafeteria
Home & School Organization
Athletic Association
Music Association
Image Release
I hereby consent to and authorize the use and reproduction, in print and electronic format by York Catholic Middle & High School and the Diocese of Harrisburg of any and all photographs and/or motion pictures captured of the subject mentioned below for any publicity purpose, including but not restricted to Internet website, brochures, newsletters, magazine, and other school or diocesan marketing applications. I understand in some case, the subject will be identified and the name printed. All images, electronic digital files, positive slides and negatives are owned by the school and/or diocese and the signer acknowledges and understands the photo likeness will be used by the school or diocese without compensation. I hereby acknowledge I am 18 years of age or older and I am providing consent on behalf of the subject mentioned in this application. I have read and understand the terms of this release and I understand this release has no time restrictions or restricted terms.
Student Responsibilities
York Catholic is committed to the continued personal, academic, and spiritual growth of each student. This commitment is one that requires a collaborative effort. The school, as well as student and parents, must be resolved to this same continued growth. Students in the schools of the Diocese of Harrisburg are expected to conduct themselves in a manner that reflects favorable on themselves, their families and their schools. Students are expected to have respect and to show consideration to the other students in the school and to the harmonious school atmosphere. Students are to recognize their individual responsibilities as a condition for their remaining at the school. Students are expected to conduct themselves inside and outside of school and at school-sponsored activities in a manner that reflects the moral teaching of the Catholic Church. Failure to do this may result in disciplinary action, including expulsion. The Discipline System is designed to safeguard the rights of others and make each student responsible for his or her own actions without being oppressive. York Catholic has the obligation to help students become acceptable and functioning members of society. A code of acceptable behavior comprises the Discipline System at York Catholic and is endorsed by the Student Council, Faculty and Administration. The Discipline System extends to all school-related activities. The conduct of each student outside of school as well as during school does affect the reputation of York Catholic Middle & High School. Each individual shares responsibility for the good name of our school. Therefore, any student whose behavior and/or life style outside of school could reflect negatively upon the school will be liable to disciplinary action by the school and, if necessary, dismissal. All new students will be placed on probationary status through the first marking period. At the end of the period, each student’s grades, attendance, and conduct will be evaluated. If a student does not meet the school’s requirements, he/she may be dismissed from York Catholic.
**The parents and/or guardians of the applicant student hereby agree that they and their applicant student will abide by each of the policies and procedures that may be adopted from time to time by the Diocese of Harrisburg and by York Catholic Middle & High School, including but not limited to those set forth or referred to in York Catholic High School’s and/or the Diocese of Harrisburg’s student handbook.
Signature of Mother or Legal Guardian
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Date
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Year
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Signature of Father or Legal Guardian
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Date
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Day
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