Applications

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Student Information
Student's First Name REQUIRED Please fill out this field. Please enter valid data.
Student's Last Name REQUIRED Please fill out this field. Please enter valid data.
Student's Gender REQUIRED Male Female Please fill out this field.
Birth Date REQUIRED Please fill out this field. Please enter valid data.
Applying for admission to grade REQUIRED Please fill out this field.
Students Age as of 9/1/15 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.
Ethnic background (check one) Asian Asian Indian/Native Alaskan Black/African American White Hispanic Native Hawaiian/Pacific Islander Multi-Racial
Student's Religion REQUIRED Please fill out this field. Please enter valid data.
Sacraments Received Baptism Reconciliation First Eucharist
Date/Where REQUIRED Please fill out this field. Please enter valid data.
Home language survey
Languages spoken by the child Maximum 250 characters Please enter valid data.
Languages spoken at home Maximum 250 characters Please enter valid data.
Medical History
Does your child have any special needs? Please enter valid data.
Has your child ever been diagnosed with a learning disability, behavior disorder or other condition such as Attention Deficit or Hyperactivity? If so please explain. Also, please attach any educational or psychological testing.
Is your child currently on any medication?
If yes, please explain Please enter valid data.
Please describe any illness, diseases, psychological issues, or physical disabilities which have affected or may affect your child's health, schoolwork, or participation in the school's athletic program
CHURCH AFFILIATION
Family History
Please list name and ages of applicant's siblings Please enter valid data.
Parent's marital status Married Separated Divorced * Father remarried * Mother remarried *
Student living with Mother & Father Mother Father Guardian * Mother & Stepfather Father & Stepmother Relative * Other **
** Please specify Please enter valid data.
*In the case of a divorce, parents/guardians must provide the school with a copy of the divorce decree if child custody is restricted. The school cannot enforce custody orders without complete documentation on file.
FATHER/GUARDIAN
Please Check Mr. Dr. Deceased
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Home 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.
Home Email REQUIRED Please fill out this field. Please enter an email address.
Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Place of employment REQUIRED Please fill out this field.
Work Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Work Email Please enter an email address.
Religion Please enter valid data.
MOTHER/GUARDIAN
Please Check Mrs. Ms. Dr. Deceased
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Home Address REQUIRED Please fill out this field.
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.
Home Email REQUIRED Please fill out this field. Please enter an email address.
Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Place of employment REQUIRED Please fill out this field.
Work Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Work Email Please enter an email address.
Religion Please enter valid data.
STEPPARENT
Please Check Mr. Dr. Deceased
First Name Please enter valid data.

Last Name Please enter valid data.
Home Address Please enter an email address.
City Please enter valid data.

State

Zip Please enter a zip code.
Home Email Please enter an email address.
Cell Phone Number Maximum 20 characters Please enter a phone number.
Place of employment
Work Phone Number Maximum 20 characters Please enter a phone number.
Work Email Please enter an email address.
Religion Please enter an email address.
Religion Please enter valid data.
STEPPARENT
Please Check Mrs. Ms. Dr. Deceased
First Name Please enter valid data.

Last Name Please enter valid data.
Home Address Please enter an email address.
City Please enter valid data.

State

Zip Please enter a zip code.
Home Email Please enter an email address.
Home Phone Number Maximum 20 characters Please enter a phone number.
Cell Phone Number Maximum 20 characters Please enter a phone number.
Place of employment
Work Phone Number Maximum 20 characters Please enter a phone number.
Work Email Please enter an email address.
SCHOOL INFORMATION
Student's previous school REQUIRED Please fill out this field.
Dates/grades attended REQUIRED Please fill out this field.
Reason for desire to transfer REQUIRED Please fill out this field.
SCHOLASTIC INFORMATION
Has your child been suspended or asked to leave any school? REQUIRED Please fill out this field.
If yes, please explain
Has your child had academic difficulty? REQUIRED Please fill out this field.
If yes, please explain
Has your child ever been in a gifted/talented and/or honors program? REQUIRED Please fill out this field.
If yes, indicate grade(s)
Has your child ever had educational testing? REQUIRED Please fill out this field.
If yes, indicate grade(s)
Results of testing
Has your child ever been in a special education program? REQUIRED Please fill out this field.
If yes, indicate grade(s)
Type of classes
Has your child ever been in a speech therapy program? REQUIRED Please fill out this field.
If yes, indicate grade(s)
Has your child ever received accommodations in school? REQUIRED Please fill out this field.
If yes, indicate grade(s) and subject/s
Has your child ever been retained? REQUIRED Please fill out this field.
If yes, indicate grade(s)
Has your child ever skipped a grade? REQUIRED Please fill out this field.
If yes, indicate grade
Is there any other information which you feel might be useful to us?
ST. THERESA CATHOLIC SCHOOL ALUMNI
Has anyone in your family previously attended St Theresa School? REQUIRED Please fill out this field.
If yes, please list name, graduation date and relationship to child
How did you hear about St. Theresa Catholic School in Memorial Park REQUIRED Please fill out this field.
PARENTS/GUARDIAN-PLEASE READ AND SIGN BELOW
I hereby certify that all the information given on this application is true, complete and correct. REQUIRED Please fill out this field.
Date REQUIRED Please fill out this field. Please enter a date.
**Please understand that your application is not complete until you have paid the application fee of $150.00. Contact Kurt Kleeman, Admissions Director at 713.864.4536 to make a payment over the phone or can send by check. Please address and send payment to St.Theresa Catholic School, 6623 Rodrigo Street. Houston, Texas 77007.
I Agree Please select this field.

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