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Parent Authorization

PARENT AUTHORIZATIONS

ST. MARY’S SCHOOL - PONTIAC, IL

Directions: After reading each statement, place a check mark on the line to the left of the statement.

Please sign your child’s name and your name on the appropriate lines at the bottom and

fill in the date. PLEASE SIGN ONE SHEET FOR EACH CHILD.

_____ ILLINOIS FREE TEXTBOOK LOAN PROGRAM

I hereby request the loan of a free textbook in accordance with Public Act 79-971. I understand

that this request will remain valid as long as my child is enrolled in St. Mary’s School, Pontiac, IL

and that I may at anytime withdraw this request. (St. Mary’s School participates in this program.)

_____ ASBESTOS MANAGEMENT PLAN

I have been informed of the presence of asbestos in non-friable form in St. Mary’s School. I

understand that I have the right to examine the Asbestos Management Plan on file in the school office.

_____ NURSING HOME MASSES (Grades 3 – 8)

I request that my child named below be allowed to go to the Pontiac nursing homes on a rotating

basis for the 10:00 AM Mass (2^nd Monday-Livingston Manor, 3^rd Monday-Evenglow Lodge,

4^th Monday- Asta Care Center). Students will be transported by car.

_____ PICTURE PROCEDURE

I give my permission for my child to have his/her picture taken for possible use in the school and parish newsletters, newspapers, school yearbook or for educational presentations.

_____ PHONE NUMBERS

I give my permission for my child’s name, address, parent’s name and phone numbers to be listed

in the family directory used by faculty, staff, and school organizations.

_____ CENTRAL SCHOOL CLASSES

If my child is placed in a special class, including, but not limited to, speech, occupational therapy,

etc., I give my permission for him/her to attend such classes at Central School. (Children in

Grades K – 5 will be escorted across the street by St. Mary’s personnel or volunteers.)

_____ PONTIAC PUBLIC LIBRARY/HEARTLAND COMMUNITY COLLEGE/LIONS PARK

I give my permission for my child to walk to Pontiac Public Library and/or Heartland Community

College for the purpose of library and/or computer instruction or research. , or Lion’s Park for PE in warmer

weather under the supervision of his/her classroom or special subject teacher. I also give my permission for my

child to be driven by parent volunteers or school employees when such transportation is arranged for by the

teacher due to weather or schedule constraints.

_____ SCHOOL WEBSITE

I give permission for my child to have his/her picture or name included on the school internet web page

for activities, awards, and recognition. (Pictures will not be identified.)

_____ STUDENT DISCIPLINE POLICY/ST. MARY’S SCHOOL HANDBOOK

"I (we) agree to be governed by the school policies as stated in the St. Mary’s

School Student Handbook and to see that my (our) child(ren) follow these policies."

_____ I will use the internet to access the Student/Parent Handbook and will not need a paper copy.

_____ I will need a hard copy of the Student/Parent Handbook and will pick it up at the fall registration.

_____ I will use the internet to access the weekly school newsletter and will not need a paper copy.

_____ My child will be riding the bus to and from (circle one or both) school. Bus #’s__________________

*IN ALL MATTERS INVOLVING TRANSPORTATION OF MY CHILD, I HEREBY RELEASE AND SAVE HARMLESS ST. MARY’S SCHOOL, ITS EMPLOYEES, AND THOSE ADULTS ACTING AS CHAPERONES.

(STUDENT’S NAME) (STUDENT’S GRADE)

(SIGNATURE OF PARENT OR GUARDIAN) (DATE)

St. Mary's School Uniform Sweatshirts Order Form $10 youth & adult small-XL Please add $1 for every size after 2XL Please make checks payable to St. Mary's School. Sweatshirts will be sent home with your oldest child. Sizes: YOUTH: Small 6-8, Medium 10-12, Large 14-16 ADULT: Small, Medium, Large, XL, 2XL, 3XL, 4XL, 5XL
	Sweatshirt Size
Name	Please identify Y (youth) or A (adult)	Price	Quantity	Total Price
		$10.00

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St. Mary’s School

414 N. Main

Pontiac, IL 61764

(815) 844-6585

Fax: (815) 844-6987

E-mail: smsprinc@mchsi.com

Dear Parents:

Please find below and on backside, medication requests which are to be filled out by you and/or

by your doctor if medication is to be dispensed during the school day to a student.

ALL MEDICATIONS MUST BE SENT TO SCHOOL IN THE ORIGINAL CONTAINER.

PRESCRIPTION MEDICATION MUST BE IN A CURRENT PRESCRIPTION VIAL WITH THE DOSAGE DIRECTIONS ON THE LABEL.

Students are not permitted to keep medicine in their classrooms or bookbags. Inhalers for severe asthma and cough drops may be kept in the

classroom and must be given to the classroom teacher. All medication must be kept in the school office where the dispensing will be supervised

by office personnel.

Thank you for your cooperation in this matter.

St. Mary’s School Administration & Staff

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REQUEST FOR STUDENT USE OF NON-PRESCRIBED MEDICATION

I request that _____________________________________be allowed to self-administer the

(Name of Student)

______________________________________which I am sending to school. He/She is to take

(Name of Medication)

_______________ of this medication at approximately__________a.m._____________p.m. and

(Amount of dose) (Time to give dosage(s)

understands that he/she must go to the office in order to take this medicine.

Parent Signature:___________________________________________Date:_________________

NOTE: If this medication is for a recurring problem, please explain the circumstances under which

the medicine should be administered and the dosage to be given:

_____________________________________________________________________________________

_____________________________________________________________________________________

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PRESCRIPTION MEDICATION REQUEST FORM

(To be filled out by parent)

I request that __________________________be administered to __________________________

(Name of Medication) (Name of student)

at school. The medication must be taken to school in a container appropriately labeled by a

pharmacy or physician.

Parent Signature:___________________________________ Date:________________________

Parent Phone Number:_____________________Other Emergency Phone:___________________

TO BE FILLED OUT BY PHYSICIAN

Name of Student:_____________________________________________________________

Diagnosis:___________________________________________________________________

Date of Prescription:

Medication to be given:

Dosage:

Times Medication Is given Per Day (24 hours):

Discontinuation Date:

Possible Side Effects:

Doctor’s Signature: Date:

ST. MARY’S SCHOOL_________________________________________
414 N. Main Street TEL. (815)844-6585

Pontiac, IL 61764 FAX (815)844-6987

E-MAIL smsprinc@mchsi.com

Spring, 2008

Dear St. Mary’s Parents:

It is that time of the year when we need to make our rosters for next year’s classes and order materials and supplies. We need to verify that your children will be returning to St. Mary’s School for the 2008-2009 school year. Book fees will be $165.00 for next year. Tuition will be increased as noted in the enclosed letter.

Please be kind enough to complete and return the bottom of this form by Monday, May 12.

FAMILY NAME_______________________________________________

_____Our child(ren) will be enrolled in St. Mary’s for 2008-2009.

Names: ___________________________ Grades: ______

___________________________ ______

___________________________ ______

___________________________ ______

___________________________ ______

_____Our child(ren) will not be returning to St. Mary’s in 2008-2009.

Reason:_________________________________________________________________

TUITION/BOOK FEE AGREEMENT

REGISTRATION

      A non-refundable one-time registration fee of $25.00 is charged when a student applies for

admission to St. Mary’s School.

BOOK FEE

     A book fee of $150.00 will be charged for each student in kindergarten through eighth grade.

This fee covers the cost of workbooks, textbook rental, and other consumable materials and

educational resources needed during the year. Student book fees MUST be paid at registration

in August.

TUITION

Tuition rates are reviewed in the spring and are subject to change.

ACTIVE PARISHIONERS                  MISSION FAMILIES      NON-PARISHIONERS

Kindergarten   $704/year                    $804/year                                $1247/year

Grades 1-8:

1 student        $1,408/year                 $1,508/year                             $3,362/year

2 students      $2,035/year                 $2,135/year                             ----------

3 or more       $2,101/year                 $2,201/year                             ----------



     Only families who are properly registered with the parish, fulfill their Mass attendance obligations,

regularly support the parish according to their means, and are involved in parish activities as much

as possible will be considered “active parishioners.” All others must pay the non-parishioner rate.

PAYMENTS

    Rates may be paid in full at the time of registration or in 10 monthly payments (August – May).

Payments are due on the first of each month with the first payment due on August 1.

Payments will be considered past due after the tenth day of each month, and all tuition must be

paid by May 10.

     If tuition becomes 30 days delinquent, the student(s) may be dismissed from school, and/or the account will be

charged 1% per month interest on the unpaid balance. Students will not be

allowed to begin the next semester unless their accounts are made current or payment arrangements have been made.

     Tuition payments only are to be paid to the parish office at 119 E. Howard Street. Payments

may be sent to the school with the students and will be forwarded to the parish secretary.

     All other fees are paid to the school office during regular office hours or can be sent in an

envelope with the student’s name, the amount of payment, and its use.

OTHER POLICIES

1.            Students enrolled for part of a month owe tuition for the entire month.

2.            Fees paid are non-refundable.

3.            Checks returned by a bank for insufficient funds will incur a $10.00 charge.

CONTRIBUTIONS

     The financial stability of the school is dependent on generous, tax-deductible gifts of

friends, parents, grandparents, and church. Monthly contributions enable us to keep

tuition at an affordable rate.

TUITION AID

A Spalding Scholarship Program has been established to assist families who need assistance in paying tuition.

This is a two step process that must be completed and to the Diocesan office by February 15th to be considered.

Scholarship application forms are available in the office in January and are kept confidential.

Please fill out and return the form below.

I certify that I have read and understand the terms of the above agreement.

I agree to pay the stated amount for my situation (or the amount set by the Financial Aid Committee).

_____I am an Active Parishioner. I regularly support St. Mary’s Church by using my

           Sunday envelopes. (Envelope #_______)

_____I am not an Active Parishioner. I will be paying the Non-Parishioner rate.

Name of Parent/Guardian (Please Print)___________________________________________

Signature of Parent/Guardian___________________________________Date_____________

Please enroll the following child(ren) for the 2006-2007 school year:

1. ______________________________________________________        Grade:___________

2. ______________________________________________________        Grade:___________

3. ______________________________________________________        Grade:___________

4. ______________________________________________________        Grade:___________

5. ______________________________________________________        Grade:___________