Bishop Canevin High School

Applicant's Name

First Name*

Middle Name*

Last Name*

Gender*

Male

Female

General Information

Nickname

Home Telephone Number*

Birth Date (mm/dd/yyyy)*

Parish/Church*

Catholic or non-Catholic*

Catholic

Non-Catholic

Home Address*

City*

State*

Zip Code*

Public School District*

Present School*

Dates Attended*

Previous School(s)

Dates Attended

Present Grade*

Applying to Grade*

Father/Step-Father/Guardian

Choose One*

Father

Step-Father

Male Guardian

First Name*

Middle Name*

Last Name and Suffix*

Address*

City*

State*

Zip Code*

Home Telephone Number*

Cell Phone Number*

Business Phone Number

E-Mail Address*

Employer*

Position/Occupation*

Father/Step-Father/Guardian is a Canevin Catholic or Bishop Canevin Graduate?*

Yes

If yes, what year?

Mother/Step-Mother/Guardian

Choose One*

Mother

Step-Mother

Female Guardian

First Name*

Middle Name*

Maiden Name*

Last Name*

Address*

City*

State*

Zip Code*

Home Telephone Number*

Cell Phone Number*

Business Phone Number

E-Mail Address*

Employer*

Mother/Step-Mother/Guardian is a Canevin Catholic or Bishop Canevin Graduate?*

Yes

If yes, what year?

Applicant Resides with*

Both Parents

Father

Mother

Step-Father

Step-Mother

Other:

Name of Person(s) Responsible for Paying Tuition*

If parents do not reside together, should the parent at the 2nd household also receive school mailings? (If yes, please give name and address)

Yes

Name (2nd Household)

Address, City, State, Zip Code (2nd Household)

The Following Information Is Used to Gather Demographic Information About Our Students For Reporting Purposes.*

American Indian/Native Alaskan

Asian

Black

Native Hawaiian/Pacific Islander

White

Two or More Races

Student Ethnicity*

Hispanic

Non-Hispanic

Brothers & Sisters

Name

Age

Gender

Male

Female

Present Grade

Present School

Name

Age

Gender

Male

Female

Present Grade

Present School

Name

Age

Gender

Male

Female

Present Grade

Present School

Name

Age

Gender

Male

Female

Present Grade

Present School

Is the student's main language English?*

Yes

Does the student have a learning disability?*

Yes, explain below

If yes, please explain.

If yes, does the student have an I.E.P. (Individualized Learning Plan)?

Yes

Does the student have any physical disability or health issue (e.g. vision, hearing, asthma, allergies, etc.) of which the School Personnel should be made aware?*

Yes, please explain below

If yes, please explain.

If the above information changes, notify the Counseling Department immediately.

I hereby grant Bishop Canevin High School administration permission to request and examine all information provided by my previous school(s) attended in considering my application for acceptance, admittance and course placement, including: Academic Records, Standardized Test Scores, Attendance Record, Conduct/Discipline Record, Health Record, Psychological Record, Principal and/or Teacher Recommendations.*

Yes

Signature of Student*

Date (mm/dd/yyyy)*

Signature of Parent/Guardian*

Date (mm/dd/yyyy)*

Signature of Parent/Guardian*

Date (mm/dd/yyyy)*

Bishop Canevin A Jesuit-inspired High School

Please fix the highlighted areas below before submitting.

Application for Admission 2019-20

If the above information changes, notify the Counseling Department immediately.