Saint Mary of the Immaculate Conception School 2680 Stoney Ridge Road Avon, Ohio 44011 Phone - 440-934-6246

Legal Custody Information Sheet 2010-2011 School Year

Student Last Name: _______________________________________ Student Address: _________________________________________ City & ZipCode: _________________________________________ First Name: Grade: _________________________ _________________________

Date of Birth: _________________________

Child currently resides with:

_____ both parents _____ father as custodial _____ mother as custodial _____ grandparent(s) with legal custody _____ Other Please explain: ________________________________ _________________________________________________________

RESIDENTIAL PARENT/GUARDIAN INFORMATION:

Name: __________________________________________ Daytime Phone: Cell/Work Phone: Address: ________________________________________ City and Zip Code: ______________________ ______________________ ______________________________

If there is a court order (or pending order) affecting the custody and or residence of the child, a Certified Copy, including the Case Number and those sections of the order referring to visitation rights and contacts with the school must be attached to this form. Also include the page(s) bearing the judges signature and court seal. This copy should include any and all modifications made at the date of registration of the child in this school. It is also the responsibility of the parents to inform the principal or school of any subsequent modifications during the childs tenure at the school. ADDITIONAL INFORMATION: Does the non-custodial/residential parent have visitation rights? Is there a court order decision that states that the non-custodial/residential parent should NOT receive school information or attend school activities? Is the non-custodial/residential parent responsible for any part of the financial responsibilities of the childs education? _____ Yes _____ Yes _____ Yes _____ No _____ No _____ No

A complete copy of the schools procedures dealing with family custody situations can be found in the School Handbook. Signature of Parent/Guardian: __________________________________________
Revised 6/2010 Legal Custody

Date: _________________________