Registration Form

Mother's Name REQUIRED Please fill out this field. Please enter valid data.

Mother's Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.

Family email REQUIRED Please fill out this field. Please enter an email address.

Mother's 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.

Father's Name REQUIRED Please fill out this field. Please enter valid data.

Father's Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.

Father's Email REQUIRED Please fill out this field. Please enter an email address.

Father's 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.

Check what applies to your family. REQUIRED Sacred Heart Parishioner Current Sacred Heart School family Neither Please fill out this field.

First Emergency Contact Name & Phone Number (other than parent) REQUIRED Please fill out this field. Please enter valid data.

Second Emergency Contact Name & Phone Number (other than parent) REQUIRED Please fill out this field. Please enter valid data.

I give permission for my child (ren) to leave Sacred Heart School with the following person(s) named below. This person must be able to produce a picture ID upon request. It is the responsibility of the parents to notify Sacred Heart, in writing, of any changes.

People Authorized to pick up child(ren) REQUIRED Please fill out this field.

If there is a separation, divorce, restraining order or other custody problems of which we should be aware, please explain and provide legal paperwork to the office:

Divorce/custody information

Name of person(s) who may NOT pick up your child (ren):

People NOT authorized to pick up child(ren) REQUIRED Please fill out this field.

Emergency Medical Authorization

As the parent/guardian of the child registering, I give my permission to the staff of Sacred Heart to secure emergency medical treatment when parents or guardians cannot be reached. I understand the information in this document will be shared with the personnel that provides services to my child (ren). School personnel may contact my child (ren)’s health provider regarding my child (ren)’s health and exchange information. Every effort will be made to notify parents immediately in case of emergency. In the event of emergency, it would be necessary to have the following information.

Name of Physician REQUIRED Please fill out this field. Please enter valid data.

Physician Address REQUIRED Please fill out this field. Please enter valid data.

Physician Phone Number REQUIRED Please fill out this field. Please enter valid data.

Name of Dentist REQUIRED Please fill out this field. Please enter valid data.

Dentist Address REQUIRED Please fill out this field. Please enter valid data.

Dentist Phone Number REQUIRED Please fill out this field. Please enter valid data.

Health Insurance REQUIRED Title 19 Hawk-I Private Insurance Please fill out this field.

Allergies & Permissions

Please initial under each permission agreement.

Allergies REQUIRED Please fill out this field. Please enter valid data.

Sunscreen Permission:

I give permission for the Sacred Heart School staff to apply sunscreen to my child. If my child has an allergy to a certain sunscreen, I will inform the staff. I will provide sunscreen for my child if I wish to have it applied. Initials:

Sunscreen permission Initials REQUIRED Please fill out this field. Please enter valid data.

Insect Repellent:

When public health authorities recommend use of insect repellents due to a high risk of insect-borne disease, only repellents containing DEETS are used. Staff can apply insect repellent no more than once a day and only with written parental permission. Parents must provide the insect repellent to the school.

Insect Repellent Initials REQUIRED Please fill out this field. Please enter valid data.

Field trips:

I give permission for my child to go on field trips while at Sacred Heart School. I understand the children may ride on a bus and will be supervised by Sacred Heart Staff at all times.

Field Trip Initials REQUIRED Please fill out this field. Please enter valid data.

Emergency Treatment:

I hereby give permission for my child to receive emergency treatment (first aid/CPR) by a qualified Sacred Heart School Staff member. This permission includes transportation by ambulance if needed. In the event I cannot be contacted, I give consent to dental, medical and hospital professionals to treat my child if deemed necessary for the safeguard of my child’s health. In case of an emergency, I agree to pay all costs of treatment and transportation.

Emergency Treatment Initials REQUIRED Please fill out this field. Please enter valid data.

Health File Access:

I give permission for the Sacred Heart staff, administrator, and school secretary to access my child’s health files.

Health File Access Initials REQUIRED Please fill out this field. Please enter valid data.

Do you give permission for your child's photo and name to appear on Facebook, school website, newspaper, or other media outlets for educational and marketing purposes? If no, your child's face will be blurred to protect their privacy. REQUIRED Yes No Please fill out this field.

Do you give permission for your child to appear on video for educational and marketing purposes only? (Facebook Live, marketing videos, other media for marketing). REQUIRED Yes No Please fill out this field.

Any other comments and/or questions? REQUIRED Please fill out this field.

Parent/Guardian Digital Signature: I certify that the above information is correct to the best of my ability.

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

Date REQUIRED Please fill out this field. Please enter valid data.

Sacred Heart Catholic School

Spencer, Iowa

Registration Form

ECC Registration Form