PLEASE PRINT OR TYPE. PLEASE RETURN THIS FORM ALONG WITH A RECENT REPORT CARD OR TEACHER EVALUATION AND MOST RECENT STANDARDIZED TEST (if applicable).

Date _____________________ School Currently Attending ________________________________________

This application is for: [ ] Preschool  [ ] Kindergarten  [ ] Grade _____

Child’s Full Name ________________________________ Preferred Name ______________ [ ] Boy  [ ] Girl

Home Address ___________________________________ City _____________________ Zip __________

Telephone ___________________________________________ E-mail address ___________________________

Child’s Age __________ Date of Birth ________________ Place of Birth __________________________

Father’s Full Name _______________________________ Occupation ____________________________

Employer _______________________________________ Business Telephone _____________________

Mother’s Full Name ______________________________ Occupation ____________________________

Employer ______________________________________ Business Telephone _____________________

Mother’s Maiden Name ___________________________

Are Parents [ ] Divorced?  [ ] Separated? If yes, please give:

Father’s Address __________________________________________________________________________

Mother’s Address _________________________________________________________________________

Tuition bill should be mailed to: _____________________________________________________________

Child lives with: [ ] Both Parents  [ ] Father  [ ] Mother  [ ] Other (relationship) ___________________

Child’s Previous School Experience (list most recent first, including present school):

Religious affiliation ___________________________________________________________

The California School Immunization Law requires that children be up-to-date on their immunizations to attend school or childcare. To find out current immunization requirements, or if you have any questions about immunizations, please contact your child's Doctor.

Was child adopted: Yes [ ]  No [ ]

Is there a history of Diabetes, Rheumatic Fever, Epilepsy, Allergy, or any physical impairment (glasses, hearing aid, etc.) which may necessitate your child being given special attention?

___________________________________________________________________________________________________

Why did you choose St. Martin’s School for your child?

_________________________________________________________________________________________________

How did you hear about St. Martin’s School?

___________________________________________________________________________________________________

Reason for leaving last school?

___________________________________________________________________________________________________

Person, other than parent or guardian, who may be notified in case of Emergency:

Name __________________________________________ Telephone ____________________________

Relationship to child ____________________________

Child’s physician _______________________________ Telephone ____________________________

St. Martin-in-the-Fields Episcopal School admits students of any race, religion, or national or ethnic origin and does not discriminate in the administration of its educational policies, admission policies, or other school administered programs.

In signing this form you are granting permission for us to contact your child's previous schools.

Signed: