Application 2019-20

Family Last Name REQUIRED Please fill out this field. Please enter valid data.

Were you referred by a current ICS family? Yes No We are a current ICS Family

If yes, please let us know the ICS family who referred you so we can thank them Please enter valid data.

Number of children to be registered REQUIRED Please fill out this field.
Student 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Ethnicity REQUIRED Please fill out this field.
- Grade September 2019 REQUIRED Please fill out this field.
- School and location transferring from Please enter valid data.
- My child has received the following Sacraments (new students please submit certificate copies with registration) Baptism First Holy Communion Confirmation None
- Has the applicant ever been diagnosed or evaluated as having any learning disabilities? Yes No
- Does the applicant have an Individual Education Plan (IEP) or 504 Support Plan? Yes No
- Has the applicant ever received any supplemental education services, public or private? Yes No
- Has the applicant ever received severe disciplinary action at school (resulting in suspension or expulsion)? Yes No
Student 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Ethnicity REQUIRED Please fill out this field.
- Grade September 2019 REQUIRED Please fill out this field.
- School and location transferring from Please enter valid data.
- My child has received the following Sacraments (new students please submit certificate copies with registration) Baptism First Holy Communion Confirmation None
- Has the applicant ever been diagnosed or evaluated as having any learning disabilities? Yes No
- Does the applicant have an Individual Education Plan (IEP) or 504 Support Plan? Yes No
- Has the applicant ever received any supplemental education services, public or private? Yes No
- Has the applicant ever received severe disciplinary action at school (resulting in suspension or expulsion)? Yes No
Student 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Ethnicity REQUIRED Please fill out this field.
- Grade September 2019 REQUIRED Please fill out this field.
- School and location transferring from Please enter valid data.
- My child has received the following Sacraments (new students please submit certificate copies with registration) Baptism First Holy Communion Confirmation None
- Has the applicant ever been diagnosed or evaluated as having any learning disabilities? Yes No
- Does the applicant have an Individual Education Plan (IEP) or 504 Support Plan? Yes No
- Has the applicant ever received any supplemental education services, public or private? Yes No
- Has the applicant ever received severe disciplinary action at school (resulting in suspension or expulsion)? Yes No
Student 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Ethnicity REQUIRED Please fill out this field.
- Grade September 2019 REQUIRED Please fill out this field.
- School and location transferring from Please enter valid data.
- My child has received the following Sacraments (new students please submit certificate copies with registration) Baptism First Holy Communion Confirmation None
- Has the applicant ever been diagnosed or evaluated as having any learning disabilities? Yes No
- Does the applicant have an Individual Education Plan (IEP) or 504 Support Plan? Yes No
- Has the applicant ever received any supplemental education services, public or private? Yes No
- Has the applicant ever received severe disciplinary action at school (resulting in suspension or expulsion)? Yes No
Student 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Ethnicity REQUIRED Please fill out this field.
- Grade September 2019 REQUIRED Please fill out this field.
- School and location transferring from Please enter valid data.
- My child has received the following Sacraments (new students please submit certificate copies with registration) Baptism First Holy Communion Confirmation None
- Has the applicant ever been diagnosed or evaluated as having any learning disabilities? Yes No
- Does the applicant have an Individual Education Plan (IEP) or 504 Support Plan? Yes No
- Has the applicant ever received any supplemental education services, public or private? Yes No
- Has the applicant ever received severe disciplinary action at school (resulting in suspension or expulsion)? Yes No
Student 6
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Ethnicity REQUIRED Please fill out this field.
- Grade September 2019 REQUIRED Please fill out this field.
- School and location transferring from Please enter valid data.
- My child has received the following Sacraments (new students please submit certificate copies with registration) Baptism First Holy Communion Confirmation None
- Has the applicant ever been diagnosed or evaluated as having any learning disabilities? Yes No
- Does the applicant have an Individual Education Plan (IEP) or 504 Support Plan? Yes No
- Has the applicant ever received any supplemental education services, public or private? Yes No
- Has the applicant ever received severe disciplinary action at school (resulting in suspension or expulsion)? Yes No

As a way of sharing good things that happen at ICS, we intend to submit press releases and photographs to local newspapers and post to the ICS social media sites. Please choose one option from the list below.

Thank you for your cooperation and we look forward to many "photo opportunities" and many good things to share!

My child(ren) May be photographed with name May be photographed without name May not be photographed

Please Note: This does not include school functions, performances, and events. If you (parent/guardian) wish for your child not to be included in these group photos/videos you (parent/guardian) are responsible for removing your child from participating.

Tuition Payment Preference Option #1: Full Payment by Check on/before August 1, 2019 Option #2 - Via FACTS: 2 Payments due Aug 2019 & Feb 2020 Option #3 - Via FACTS: 10 Payments Aug 2019 - May 2020

Does your family intend to participate in the ICS Scrip Program? Yes No, we will pay the buyout amount. N/A, We are a preschool only family

Does your family intend to participate in the ICS Service Hour Program? Yes No, we will pay the buyout amount. N/A, We are a preschool only family

Number of Parents/Guardians REQUIRED Please fill out this field.
Parent/Guardian 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Work Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Occupation REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Do you wish to be listed in the School Directory Yes No
Parent/Guardian 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Work Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Occupation REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Do you wish to be listed in the School Directory Yes No
Parent/Guardian 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Work Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Occupation REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Do you wish to be listed in the School Directory Yes No
Parent/Guardian 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Work Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Occupation REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Do you wish to be listed in the School Directory Yes No

Parental Information

Marital Status REQUIRED Please fill out this field.

Student resides with REQUIRED Please fill out this field.

Custodial Parent/Guardian (if applicable)

Religious Preference REQUIRED Please fill out this field. Please enter valid data.

Registered Parish REQUIRED Please fill out this field.

If you answered Other, please include the name and city of your registered Parish Please enter valid data.

Will your family pursue Tuition Assistance from the Diocese and/or Immaculate Conception School? Yes No

Immaculate Conception
PARISH

Annandale, NJ

Application 2019-20

Immaculate Conception Church 316 Old Allerton Rd. Annandale, NJ 08801 Phone: 908-735-7319 \| Fax: 908-735-4552 parishoffice@iccannandale.org	Immaculate Conception School 314 Old Allerton Road, Annandale, NJ 08801 Phone: (908) 735-6334 \| Fax: (908) 238-0724 info@icsclinton.org