St. Teresa Catholic High School--Online Application

Online Application

Student's Information
First Name
Middle Initial
Last Name
Gender
Address Line 1
Address Line2 (if needed):
City
Zip Code:	xxxxx-xxxx (five digits will suffice)
Home Phone:	xxx-xxxx
Cell Phone (if applicable):	xxx-xxxx
Birth Date:	xx/xx/xxxx
Birth City:
Birth State:
Birth Country:
Last School Attended:
Entrance Grade:
Expected Entrance Date:	xx/xx/xxxx
Religious Preference:
Parish Church:
Race:

Family Information
# of Students @ St. T:
Student lives with:	select all that apply: Both parents Mother/Step-Mother Father/Step-Father Grandparents Other

Father's Information
First Name
Middle Initial
Last Name
Address Line 1
Address Line2 (if needed)
City
State
Zip Code	xxxxx-xxxx (five digits will suffice)
Email Address
Home Phone	xxx-xxx-xxxx
Cell Phone (if applicable)	xxx-xxx-xxxx
Place of Employment
Occupation
Business Address
Business Phone	xxx-xxx-xxxx
Business Cell Phone (i/a)	xxx-xxx-xxxx

Mother's Information
First Name
Middle Initial
Last Name
Address Line 1
Address Line2 (if needed)
City
State
Zip Code	xxxxx-xxxx (five digits will suffice)
Home Phone	xxx-xxx-xxxx
Email Address
Cell Phone (if applicable)	xxx-xxx-xxxx
Place of Employment
Occupation
Business Address
Business Phone	xxx-xxx-xxxx
Business Cell Phone (i/a)	xxx-xxx-xxxx

Emergency/Medical Information
Contact 1 Name
Contact 1 Phone	xxx-xxx-xxxx
Contact 1 Relationship
Contact 2 Name
Contact 2 Phone	xxx-xxx-xxxx
Contact 2 Relationship
Contact 3 Name
Contact 3 Phone	xxx-xxx-xxxx
Contact 3 Relationship
Contact 4 Name
Contact 4 Phone	xxx-xxx-xxxx
Contact 4 Relationship
Family Doctor
Family Doctor's Phone
Preferred Hospital
Allergies/Med Conditions
The school may apply first aid treatment until the family can be contacted:
We give our consent for the school to use its own judgment in securing medical aid and ambulance services in case the parents cannot be reached:
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By submitting this application, the student agrees to comply with the regulations and requirements of St. Teresa High School and to cooperate with the administration, faculty and students in maintaining high standards of conduct and scholarship and in promoting the general welfare of St. Teresa High School. It is understood that the applicant accepts registration as a student at St. Teresa subject to the above provisions.

   St. Teresa High School
   2710 North Water Street
   Decatur, Illinois 62526

Phone: 217-875-2431
Fax: 217-875-2436
Email: stadmin@st-teresahs.org