Charlotte Catholic Christ the King Catholic High School ... · Our Catholic schools work to create...

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Dear Parent/Family, Thank you for your interest in enrolling your child in the Mecklenburg Area Catholic Schools for the 2016-17 school year! We are very excited about the quality and direction of our programs and look forward to having you join the MACS family. The MACS regional system is pleased to offer nine campus locations for students: Charlotte Catholic High School (9-12), Christ the King Catholic High School (9-12), Holy Trinity Catholic Middle School (6-8), St. Mark Catholic School (K-8), Our Lady of the Assumption (PK, K-8), St. Matthew Catholic School (TK, K-5), St. Gabriel Catholic School (K-5), St. Ann Catholic School (PK,TK, K-5),and St. Patrick Catholic School (K-5). You are always welcome to visit our schools for a tour. Please call the school directly to schedule a visit. Included in this packet you will find information on our schools, admission guidelines and applications for admissions. Our admissions process is a sincere attempt to look at each child’s individual learning needs to determine if we have the most appropriate educational environment for him/her. Past school records and our testing procedures equip our admissions committee with information to best place each student. Please be sure to provide all requested documentation. Every effort will be made to assign your student to your first choice school. In the event that the first choice school has no available seats in the grade applied for, applicants are assigned to the second choice school (or third choice if the second choice school is full). If no second or third choice schools are listed, your child will be placed on a waitlist for the applied grade at the first choice school. Waitlists follow the MACS Priority Placement and also take into consideration when the application was received. In order to qualify for Catholic priority admittance and participating parishioner tuition rates, you must be verified by your pastor as a participating member of the parish listed on your application. Families relocating to Charlotte should submit a letter from their out-of-town parish indicating their participation in that parish. A participating parishioner is one who is baptized Catholic, registered in the parish, attends every Sunday and Holy Day Mass and contributes time, talent and treasure for the support of the parish. Our Catholic schools work to create an environment in which the teachings of Jesus are promoted and proclaimed as the basis of the values they teach and uphold. At the heart of the curriculum is the study of the Catholic Faith. Religion classes are an important part of each student’s academic day. Catholic parents are required to enroll their children in their parish sacramental programs for Reconciliation, First Holy Communion and Confirmation. Catholic school teachers will teach the academic remote preparation for the sacraments; however, the liturgical proximate preparation, parent meetings, and retreats are completed at the student’s family parish in which they are spiritually nurtured. This packet contains all of the information needed to begin the application process. Please visit our website at https://www.charlottediocese.org/macs to find additional application information, plus MACS Tuition Assistance applications, information on the MACS Transportation system and After School Enrichment Programs. If we can be of any assistance to you during the admissions process, please do not hesitate to call the MACS Admissions Office at (704)370-3273. Thank you for your interest and we look forward to having you as a member of the MACS family. Kindly, Rebekah Ruhle Director of Admissions RDRuhle@charlottediocese.org

Transcript of Charlotte Catholic Christ the King Catholic High School ... · Our Catholic schools work to create...

Page 1: Charlotte Catholic Christ the King Catholic High School ... · Our Catholic schools work to create an environment in which the teachings of Jesus are promoted and proclaimed as the

Dear Parent/Family,

Thank you for your interest in enrolling your child in the Mecklenburg Area Catholic Schools for the 2016-17 school year! We are very excited about the quality and direction of our programs and look forward to having you join the MACS family.

The MACS regional system is pleased to offer nine campus locations for students: Charlotte Catholic High School (9-12), Christ the King Catholic High School (9-12), Holy Trinity Catholic Middle School (6-8), St. Mark Catholic School (K-8), Our Lady of the Assumption (PK, K-8), St. Matthew Catholic School (TK, K-5), St. Gabriel Catholic School (K-5), St. Ann Catholic School (PK,TK, K-5),and St. Patrick Catholic School (K-5). You are always welcome to visit our schools for a tour. Please call the school directly to schedule a visit.

Included in this packet you will find information on our schools, admission guidelines and applications for admissions. Our admissions process is a sincere attempt to look at each child’s individual learning needs to determine if we have the most appropriate educational environment for him/her. Past school records and our testing procedures equip our admissions committee with information to best place each student. Please be sure to provide all requested documentation.

Every effort will be made to assign your student to your first choice school. In the event that the first choice school has no available seats in the grade applied for, applicants are assigned to the second choice school (or third choice if the second choice school is full). If no second or third choice schools are listed, your child will be placed on a waitlist for the applied grade at the first choice school. Waitlists follow the MACS Priority Placement and also take into consideration when the application was received.

In order to qualify for Catholic priority admittance and participating parishioner tuition rates, you must be verified by your pastor as a participating member of the parish listed on your application. Families relocating to Charlotte should submit a letter from their out-of-town parish indicating their participation in that parish. A participating parishioner is one who is baptized Catholic, registered in the parish, attends every Sunday and Holy Day Mass and contributes time, talent and treasure for the support of the parish.

Our Catholic schools work to create an environment in which the teachings of Jesus are promoted and proclaimed as the basis of the values they teach and uphold. At the heart of the curriculum is the study of the Catholic Faith. Religion classes are an important part of each student’s academic day. Catholic parents are required to enroll their children in their parish sacramental programs for Reconciliation, First Holy Communion and Confirmation. Catholic school teachers will teach the academic remote preparation for the sacraments; however, the liturgical proximate preparation, parent meetings, and retreats are completed at the student’s family parish in which they are spiritually nurtured.

This packet contains all of the information needed to begin the application process. Please visit our website at https://www.charlottediocese.org/macs to find additional application information, plus MACS Tuition Assistance applications, information on the MACS Transportation system and After School Enrichment Programs.

If we can be of any assistance to you during the admissions process, please do not hesitate to call the MACS Admissions Office at (704)370-3273. Thank you for your interest and we look forward to having you as a member of the MACS family.

Kindly,

Rebekah Ruhle Director of Admissions [email protected]

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High School Admissions Guidelines 2016-2017

Thank you for your interest in MACS! Applications for enrollment at Charlotte Catholic High School and Christ the King Catholic High School will be accepted beginning December 1, 2015. Submit a completed application for each applicant to the MACS Admission Office. An application will begin to be processed once all paperwork is complete and copies of requested information and fees have been provided.

Families are always welcome to visit our schools. If you would like to schedule a visit please call Charlotte Catholic High School 704.543.1127 or Christ the King 704.799.4400 to schedule an appointment.

MACS Priority Placement

Seats are assigned according to the MACS Priority Placement.

MACS Priority Placement ● Siblings of current MACS students who are participating Catholics● Students of current MACS teachers● Participating Catholics of a parish in Mecklenburg County and surrounding areas● Participating Catholics of a parish outside of Mecklenburg County and surrounding areas● Siblings of non-participating Catholics and non-Catholics currently attending a MACS school● Non-participating Catholics and non-Catholics

In all cases involving Catholic students, their pastor must certify (with his signature on the Parish Participation Voucher) that they are participating Catholics in order to have priority placement and be eligible for the Catholic tuition rate. In order to be eligible for the participating parishioner tuition rate, Catholic families transferring into the Charlotte area may provide a letter from the pastor at their current parish stating that they are participating parishioners.

Placement Test

A placement test will be administered for applicants interested in the 9th grade admission process. The screening will take place on Saturday, January 9th, 2016 at both Charlotte Catholic High School and Christ the King Catholic High School. Additional information and registration forms are included in the application packet.

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School Health Services

All students are required by NC General Statute 130A-154 to have appropriate required immunizations in order to attend school (all public and private schools). Students must provide proof of immunization and be in compliance with North Carolina immunization requirements prior to admission into the school. All new students must provide proof of physical examination (completed no more than 12 months prior to the anticipated date of school entry). Parents are responsible for providing these records during the application process.

Fees 2016-2017

There is a $100 non-refundable application fee (due with application). The registration for students entering K-12 is $125 per student. Upon notification of acceptance, each new family is required to pay the registration fee of $125 as a non-refundable enrollment deposit within ten business days. Families starting after the start of the 2016-17 school year must pay these fees on or before the student’s first day of school.

Tuition Assistance Program For students in grades K-12, a tuition assistance plan exists for participating Catholic families with identified financial needs. The funds are reserved for tuition and capital fees only and do not include bus, activity or graduation fees. There is a separate application form which is available on the MACS website, at the MACS office and individual school offices. A student must be accepted and registered in order to receive tuition assistance results. Grants do not cover the entire tuition cost. Not all families who apply for tuition assistance qualify.

Completed applications must be received by the deadline in order to be processed. Applications with missing information or IRS verification will not be considered until all information is provided.

First Round Deadline: March 1st – results are mailed to families in mid-to-late May

Second Round Deadline: May 1st – results are mailed to families about 8 weeks after thisdeadline ends (mid-to-late July)

After May 1st – results will be processed by PSAS on a monthly basis and the results will be sentto the families as soon as possible thereafter.

Additional Considerations

All schools in the Diocese of Charlotte admit students of any race, color, sex, religion, national and ethnic origin to all the programs and activities generally accorded or made available to students at these schools.

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Application for Admissions 2016-2017 School Year

Application for High School

Applying for the _________grade in at _____________________ month and year planning to enter Charlotte Catholic or Christ the King

2nd choice__________________________ MACS Family ID ______________

Please complete this application and return it to the MACS office with the following:

$100 nonrefundable application fee to initiate admissions process, payable to MACS

Official copy of transcript of grades, standardized test scores, GPA, and class rank

Proof of Physical Exam and Immunizations (Health Form enclosed)

Complete Principal’s Evaluation Form; Teacher Recommendation Forms:Math, Science, English and Foreign Language (enclosed)

Parish Participation Voucher (enclosed)*No admission decision can be made until ALL documents listed above have been received.

Student Information

Full Name ______ ___ Preferred Name _

Permanent Address ___ ___ ________

City State ____Zip ________

Home Telephone _ _Date of Birth ___ _______ Male Female

Has applicant ever attended a Mecklenburg Area Catholic School? yes no If yes, ____________________ year and school

Religion Roman Catholic Parish Registered In _______________ *If a Parish Participation Voucher is not

included with the application, status will City, State _ be non-participating until received

Other Name of Religion ________

How did you hear about MACS?_______________________________________________________________________

Parent Information With whom does the applicant reside? ______________________________________

Father's Name ___ ______________ ______________________________________ Title Last First M.I. Preferred Name

Occupation __ ____ _____Business Telephone __ _

Company Company Address _______ _

Cell Telephone ___________________________ Email Address_____________________________________________

Mother's Name ___ ______________ ______________________________________ Title Last First M.I. Preferred Name

Occupation __ ____ _____Business Telephone __ _

Company Company Address _______ _

Cell Telephone ___________________________ Email Address_____________________________________________

MACS USE ONLY Check #:______________

Amount:______________

Date:

For : App Fee 16-17

To be completed by Parent/Guardian

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Siblings Names of other children currently enrolled in a MACS school.

Name School Grade

Name School Grade

School Information

Currently in grade_______ Present School Name_________________________________Telephone_______________

Name of Principal/Head of School___________________________City, State, Zip______________________________

Previous Schools Attended ___________________________________________________ Grade Completed________

_________________________________________________________________________ Grade completed_________

Grades repeated, if any_____________________________________________________________________________

Has the applicant ever received auxiliary services such as outside tutoring, psychological or educational testing, speech and/or language assistance, or professional counseling? yes no

If yes, explain and please provide copies of any testing results.

______________________________________________________________

Has the applicant been hospitalized for significant medical treatment? yes no

If yes, please describe. _

_

Has a physician ever prescribed any medication for attentional or emotional concerns, or is the applicant presently receiving such medication? yes no

If yes, list medication and possible side effects. ________

_

Is your student currently receiving additional services at school? (i.e. gifted program, speech, language, or learning support) yes no

If yes, list services. ________________________________________________________________________________

________________________________________________________________________________________________

List any other health or learning considerations needed for this child. ________

_

If English is not the primary language spoken at home, what is? ____________ _

Student’s special interests, honors or activities___________________________________________________________

These statements are true and accurate to the best of my knowledge. I understand that if pertinent information is not included or falsified, that my student’s acceptance could be jeopardized or result in his/her removal from the school in the future. I enclosed a check for the application fee of $100 per student applying for admission to the Mecklenburg Area Catholic Schools.

Signature of Parent ____ __ _______________Date ________

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To be completed by Parent/Guardian

High School Placement Test for 9th grade applicants

The MACS High School Placement Test is administered each year to all 8th graders who wish to apply to high school (CCHS or CTKCHS). The placement test is scheduled for Saturday, January 9th, 2016. The test will be from 8:00 am until 11:30 am at Charlotte Catholic High School and Christ the King Catholic High School. There is no scheduled make-up test date.

Pre-registration is required for this test. The registration form below is to be completed and mailed to CCHS or CTKCHS. Registration includes a $25 fee to be paid online on the following sites:

Charlotte Catholic High School - https://charlottecatholic.americommerce.com/store

or

Christ the King Catholic High School - http://www.christthekinghs.com/page.cfm?p=361

Students are to arrive at the high school on the day of the testing by 8 am. Please bring two #2 pencils and a simple calculator. Students should bring a sweater or jacket in case the testing room is cold.

Placement test scores and an explanation of the test will be mailed to you in March 2016. For more information or any questions, please call Charlotte Catholic High School Assistant Principal, Mrs. Angela Montague at (704) 716-2454 or Christ the King Catholic High School Principal, Mr. Brendan Keane at (704) 799-4400.

Complete the entire form below and mail to either Charlotte Catholic High School or Christ the King Catholic High School (address below). To complete registration go to your school’s link above and make payment.

Student Name _____________________________________________________________________________________________ Last First M.I.

School Applied: Charlotte Catholic HS Christ the King HS

DOB _________________ Male Female Home Phone _______________________________

Father’s Name _______________________________________ Cell Phone __________________________

Mother’s Name ______________________________________ Cell Phone __________________________

Send Mail to: (circle one) Mr./Mrs. or Mr. or Ms. (name) _________________________________________

Address: __________________________________________________________________________________________________ Number and Street Name City State Zip Code

E-mail __________________________________________________________________________________

Name of Current School ______________________________________ City/State ____________________

Religion: Catholic Name of Parish/City _____________________________________ non-Catholic

Charlotte Catholic High School Attn. Mrs. Angela Montague 7702 Pineville-Matthews Road Charlotte, NC 28226

Christ the King Catholic High School Attn. Mr. Brendan Keane

2011 Crusader Way Huntersville, NC 28078

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MACS Office of Admissions Phone (704) 370-3273 Fax (704) 370-3292

Transcript Release Request

To Current Principal/Head of School: Please release records (including copies of complete transcript of grades, all standardized test scores and any other pertinent information) concerning this student. Please return completed form to: MACS Admissions Office

1123 South Church Street Charlotte, NC 28203

Our child has applied to the Mecklenburg Area Catholic Schools for admission to the _______ grade for the __________school year.

Student’s Name:_______________________________________________________________________ Last First M.I.

Home Address:________________________________________________________________________ Street City State Zip

Home Phone:__________________________________________________________________________

School Name:_________________________________________________________________________

School Address:________________________________________________________________________ Street City State Zip

Current School Telephone: Current School Fax:________________________

I,_____________________________________________(parent or guardian), do hereby declare that I am legally responsible for the release of information concerning said student, and I do hereby request and authorize_______________________________________________School to give in writing to Mecklenburg Area Catholic Schools copies of all records, including immunization records, pertaining to said student, upon receipt of this Release Request.

Signed:________________________________________________________Date:__________________ Parent or Guardian

Parent/Guardian: Please complete, sign and return to your child’s current school

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MACS Office of Admissions Phone (704) 370-3273 Fax (704) 370-3292

High School Admissions Principal Recommendation

Our child has applied to the Mecklenburg Area Catholic Schools for admission to the ________ grade for the 2016-17 school year at Charlotte Catholic High School Christ the King Catholic High School .

Student’s Name:_______________________________________________________________________________ Last First M.I.

Current School Name:__________________________________________________________________________

Current School Address:________________________________________________________________________ Street City State Zip

Current School Telephone: Current School Fax:___________________________

I,_____________________________________________(parent or guardian), do hereby declare that I am legally responsible for the release of information concerning said student, and I do hereby request and authorize

_______________________________________________School to give in writing to Mecklenburg Area

Catholic Schools copies of all records, including immunization records, pertaining to said student, upon receipt of this Release Request.

Signed:________________________________________________________Date:__________________________ Parent or Guardian

************************************************************************************* To Current Principal/Head of School: Please release records (including official copies of complete transcript of grades; all standardized test scores; recommendations from student’s math, English, science and foreign language teachers (see attached forms) and any other pertinent information) concerning this student. Please return completed form to: MACS Admissions Office

1123 South Church Street Charlotte, NC 28203

Has this student ever appeared before your Discipline Committee? yes no If yes, please comment below.

____________________________________________________________________________________________

Has this student ever been suspended from your school? yes no Please note, if yes. ________________

____________________________________________________________________________________________

How would you rate this family’s overall support of the school?_________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Signed:________________________________________________________Date:__________________________ Principal or Head of School

Parent/Guardian: Please complete student information and submit to your child’s current school

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MACS Office of Admissions Phone (704) 370-3273 Fax (704) 370-3292

High School Admissions English Teacher Recommendation

Student Name:______________________________________ ______ Grade Applying to:__________ Last First M.I.

Applying to: Charlotte Catholic High School Christ the King Catholic High School_________

Current Teacher Name: ____________________________ Current School:_______________________________

Directions: Please evaluate the candidate in the following areas by placing a check in the appropriate column.

Excellent Above Average

Average Below Average

Poor

Reading Ability/Reading Comprehension

Written Expression

Spelling

Writes Grammatically Correct Sentences

Verbal Expression

Vocabulary Range

Creativity

Organizational Ability

Works Independently

Classroom Conduct

Completion and Quality of Homework Assignments

Name of English Course this student is currently enrolled in:____________________________________________

Title/publisher/grade level of text used:____________________________________________________________

Comments:___________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

_

Signature of English Teacher: __________________________________________ Date ____________________

Thank you for the time and effort you have taken in completing this evaluation.

Please Return to: Office of Admissions

Mecklenburg Area Catholic Schools 1123 South Church St. Charlotte, NC 28203

Parent/Guardian: Please complete student information and submit to current teacher

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MACS Office of Admissions Phone (704) 370-3273 Fax (704) 370-3292

High School Admissions Foreign Language Teacher

Recommendation

Student Name:______________________________________ ______ Grade Applying to:__________ Last First M.I.

Applying to: Charlotte Catholic High School Christ the King Catholic High School_________

Current Teacher Name: ____________________________ Current School:_______________________________

Directions: Please evaluate the candidate in the following areas by placing a check in the appropriate column.

Excellent Above Average

Average Below Average

Poor

Knowledge of Parts of Speech

Vocabulary Acquisition

Willingness to Speak Targeted Language

Classroom Conduct

Completion and Quality of Homework Assignments

Foreign Language currently enrolled in:

Spanish______________

French_______________

Latin_________________

Other (please identify)___________________

Taken for High School Credit?_____YES______NO

Title/publisher/grade level of text used: _

Comments:___________________________________________________________________________________

____________________________________________________________________________________________

_

Signature of Foreign Teacher: __________________________________________ Date ____________________

Thank you for the time and effort you have taken in completing this evaluation. Please Return to:

Office of Admissions Mecklenburg Area Catholic Schools

1123 South Church St. Charlotte, NC 28203

Parent/Guardian: Please complete student information and submit to current teacher

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MACS Office of Admissions Phone (704) 370-3273 Fax (704) 370-3292

High School Admissions Math Teacher Recommendation

Student Name:______________________________________ ______ Grade Applying to:__________ Last First M.I.

Applying to: Charlotte Catholic High School Christ the King Catholic High School_________

Current Teacher Name: ____________________________ Current School:_______________________________

Directions: Please evaluate the candidate in the following areas by placing a check in the appropriate column.

Excellent Above Average

Average Below Average

Poor

Problem Solving

Grasp of New Concepts

Organizational Ability

Works Independently

Classroom Conduct

Completion and Quality of Homework Assignments

Name of Math Course this student is currently enrolled in:____________________________________________

Title/publisher/grade level of text used:____________________________________________________________

Comments:___________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

_

Signature of Math Teacher: __________________________________________ Date ______________________

Thank you for the time and effort you have taken in completing this evaluation.

Please Return to: Office of Admissions

Mecklenburg Area Catholic Schools 1123 South Church St. Charlotte, NC 28203

Parent/Guardian: Please complete student information and submit to current teacher

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MACS Office of Admissions Phone (704) 370-3273 Fax (704) 370-3292

High School Admissions Science Teacher Recommendation

Student Name:______________________________________ ______ Grade Applying to:__________ Last First M.I.

Applying to: Charlotte Catholic High School Christ the King Catholic High School_________

Current Teacher Name: ____________________________ Current School:_______________________________

Directions: Please evaluate the candidate in the following areas by placing a check in the appropriate column.

Excellent Above Average

Average Below Average

Poor

Reading Comprehension

Written Expression

Problem Solving Ability

Grasp of New Concepts

Organizational Ability

Works Independently

Classroom Conduct

Completion and Quality of Homework Assignments

Name of Science Course this student is currently enrolled in:___________________________________________

Title/publisher/grade level of text used: _

Comments:___________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

_

Signature of Science Teacher: __________________________________________ Date ____________________

Thank you for the time and effort you have taken in completing this evaluation.

Please Return to: Office of Admissions

Mecklenburg Area Catholic Schools 1123 South Church St. Charlotte, NC 28203

Parent/Guardian: Please complete student information and submit to current teacher

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Diocese of Charlotte

Catholic Schools

School Health Services

School Year 2016-2017

All students are required by NC General Statute 130A-154 to have the following

immunizations in order to attend school (all public and private schools)

1. DTP/DTaP – 5 doses

Tdap - a booster dose is required for individuals who have not previously

received Tdap and who are entering the 7th grade or by 12 years of age,

whichever comes first.

2. Polio – 4 doses

3. Hib – 2 doses (cannot be administered after age 5)

4. Hepatitis B – 3 doses

5. Varicella – 2 doses

Documentation of disease must be from a physician, nurse practitioner,

or physician’s assistant verifying history of disease, approximate date or

age of infection and a healthcare provider signature.

6. Measles – 2 doses

7. Mumps – 2 doses

8. Rubella – 1 dose

10. Meningococcal conjugate Vaccine (MCV) – 2 doses

One dose is required for individuals entering the 7th grade or by 12

years of age, whichever comes first.

A booster dose is required by 17 years of age or by entering the 12th

grade.

11. Pneumococcal conjugate vaccine (PCV) – 4 doses

No individuals 5 years of age or older is required to receive this

vaccine.

The above requirements are applied for certain age groups and whether or not

immunizations began as an infant. The school nurse reviews these requirements on an

individual basis as each student is enrolled.

Parents must provide the immunization certificate to school. The immunization

certificate may be copied. The original certificate should be retained by the family (and

updated as booster doses are received) throughout the child’s school career extending

through college.

Immunization Certificates presented to school must include:

1. Name of child, birth date, address and names of parent/guardian.

2. Full dates of each immunization dose (month, day, year)

3. Name and address of physician or clinic which administered the immunizations.

4. Certificates are to be signed or stamped by the physician or clinic.

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Revised 10/14

To be completed by your child’s physician

STUDENT HEALTH RECORD

SCHOOL GRADE

NAM E(LAST) (FIRST) (MIDDLE) BIRTH DATE SEX

FATHER AND MOTHER (MAIDEN NAME) OR GUARDIAN

ADDRESS CITY/STATE ZIP

RECORD OF IMMUNIZATION (Enter date of EACH dose - Mo/Day/Year)

VACCINE #1 #2 #3 #4 #5

DTP/DTaP

Tdap

POLIO

Hib

MMR HEPATITIS B SERIES

MEASLES #1 #2 #3

MUMPS VARICELLA #1 #2

RUBELLA MCV #1 #2

PCV

STATE LAW REQUIRES MINIMUM DOSES FOR EACH VACCINE (SEE REVERSE)

NOTE: Exemptions from NC State Immunization Law require that a statement must be on file in student’s permanent record. Exemptions must meet

requirements of the law.

Medical_______ HEIGHT__________ WEIGHT__________ BP__________ LAB REPORT__________

VISUAL ACUITY (R)__________ (L)__________ W/O Glasses/Contacts HEARING Pass__________ Fail__________

PHYSICAL EXAM NORMAL ABNORMAL PHYSICIAN’S COMMENTS

NUTRITION

SKIN AND SCALP

ENT

TEETH

EYES

HEART

LUNGS

ABDOMEN

ORTHOPEDIC

NEURO

CHECK BOX PRESENT ABSENT PHYSICIAN’S COMMENTS

EMOTIONAL/MENTAL BEHAVIOR PROBLEM

PHYSICAL HANDICAP-LIMITS ACTIVITY

RESTRICTION NEEDED

ENCOURAGE PARTICIPATION

OTHER HANDICAP/DISABILITY:

SEIZURES

ALLERGIES

ON MEDICATION (SPECIFY)

FOLLOW-UP RECOMMENDED

Cleared - I certify that I have examined the above named student and that such exam reveals no condition that would prevent this student from

participating in interscholastic sports or physical education classes.

Not cleared. If student not qualified, list reasons. _____________________________________________________

DATE of EXAM__________ PHYSICIAN’S SIGNATURE________________________________________________________

Physician’s Address

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PARISH PARTICIPATION VOUCHER

Each family expecting to be classified as a participating parishioner of a Mecklenburg Area Catholic Parish is required to complete this form, have the form signed by their pastor and return it to the MACS Business Office. Without this form, signed by your pastor, your family will be classified as a non-participating parishioner and charged the corresponding rate.

Families who are relocating to the Charlotte area must submit a voucher signed by their current pastor in order to be eligible for the participating parishioner rate. The Catholic transfer status will be valid for a six-month period. After six months, a voucher from a Mecklenburg Area Catholic Parish will be required.

Each family expecting to participate in the parish subsidy program is required to be registered and participating in a Mecklenburg Area Catholic Parish. This matter is to be clarified for each student before formal enrollment in the school system. Your status as a participating parishioner will be verified annually.

FAMILY INFORMATION (Please print or type all information) Family Name:

Address:

City: State: Zip:

Telephone Number: Previous Parish:

STUDENT INFORMATION Student Name:

Entering Grade: School:

Student Name:

Entering Grade: School:

Student Name:

Entering Grade: School:

I/We, the parents/guardians of the student(s) listed above understand: A. A registered member is one who is officially listed on the parish census.B. A participating member is one who is involved and intends continued

involvement in every Sunday and Holy Day Mass and contributes time, talent andtreasure for the support of the parish.

Parent/Guardian Signature: ______________________________ Date: ______________

Parish: _______________________________________________ Envelope No._______

I certify, as pastor of the above designated parish, that the listed parent and student(s) are participating parishioners. Pastor Signature: Date:

REVISED 1-17-2012 PRSHVCH.DOC