Admissions 1-8 grade 2021-2022 Form Child's First Name *Child's Middle NameChild's Last Name *Child's Gender *Child's Date of Birth *Child's Place of Birth *What grade will your child be entering? *Please select an optionFirst GradeSecond Grade Third GradeFourth GradeFifth Grade Sixth Grade Seventh GradeEighth GradeStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Child's Primary Contact Number *Do not include parenthesizes or dashes.Mother's Salutation *Mother's First Name (or Guardian) *Mother's Last Name (or Guardian) *Mother's Cell Phone Number *Do not add parenthesizes or dashes.Mother's Email Address *Mother's Religion *Please select an optionCatholicChristianOtherMother's Parish *Father's First Name (or Guardian) *Father's Last Name (or Guardian) *Father's Cell Phone Number *Do not add parenthesizes or dashes.Father's Email Address *Father's Religion *Please select an optionCatholicChristianOtherFather's Parish *Child Lives With *Relationship to child *Marital Status *MarriedWidowedDivorcedSingleSeparatedRemarriedPlease select one. Step Parent's First Name (if applicable)Step Parent's Last name (if applicable)Step Parent's Phone NumberStep Parent's Email AddressReligious HistoryName of church where child was Baptized Date of child's BaptismName of church where child received Holy CommunionDate of child's First Holy CommunionIf child is not Catholic, please state their Religion. *School HistoryChild's Public School DistrictTransportation *Please select an optionBus RiderCar Rider Name of previous schoolDid your child receive any special services at their previous school?IEPISTSpeechOtherPlease check all that apply.How did you hear about ICA? *Parent SignaturesBy registering my child, I agree to abide by all of the rules and regulations outlined in the Immaculate Conception Academy Handbook. Parent's Signature *Parent's Signature *Registration FeeThe non-refundable registration fee of $100 is required to complete your child's application. Make checks payable to ICA. Mail payment to ICA 903 Chestnut Street, Douglassville, PA 19518. Note:In case of separated families, custody papers MUST be made available to the school. Send MessagePlease do not fill in this field.