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Mary Queen of Apostles School

Family Survey 2024-2025


Dear Parents:

Federal programs provide essential services to students in non-public schools. Your federal tax dollars can be used by non-public schools to provide materials, services and programming. To receive the maximum amount of tax dollars for Mary Queen of Apostles School it is essential that you complete and return the enclosed survey. The return of these surveys is required before these critical funds can be awarded. 

I want to assure you that all information will be kept confidential. Only total numbers that represent the whole school are communicated to the federal programs. 

Please return the form as soon as possible. The deadline is Friday, September 1, 2024. Do not hesitate to call me if you have any questions about the survey. 

Thank you for your assistance. 

Sincerely,

Catherine M. Collett

Principal

First Parent/Guardian's Name
First Name*
Last Name*
First Parent/Guardian's Age Acknowledgment*
First Parent/Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Parent/Guardian's Signature*
Second Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Third Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Fourth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Fifth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Sixth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Seventh Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Eighth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Ninth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Tenth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Family Information

Find your family size and the annual gross income level listed beside it on the chart printed below

Family Size   Annual Rate

1*           $ 27,861

2            $ 37,814

3            $ 47,767

4            $ 57,720

5            $ 67,673

6            $ 77,626

7            $ 87,579

8            $ 97,532

For each additional family member add +$ 9,953

*This may be a foster child, an emancipated youth, or a special education child over age 18.

Note: If you are paid on a weekly or monthly basis, please multiply that amount into an annual figure for comparison based on the weeks or months you actually work each year.


Is your annual income equal to or less than this amount? (Please reference the Family Size/Annual Rate chart above)
Is your family eligible for food stamps?
Are you receiving TANF Cash Assistance? (Formerly AFDC or Public Assistance)
Are any of your children eligible to receive medical assistance under the Medicaid program?
We have not answered any of the above questions because we do not wish to share this information in writing.*
Family Name *
# of family members *

Address (home location, not mailing) *
Public school district in which you reside: *
Child 1 Information
Full Name *
Grade Level *
Public school building the child would attend if you had not chosen our school: *
Child 2 Information (if applicable)
Full Name
Grade Level
Public school building the child would attend if you had not chosen our school:
Child 3 Information (if applicable)
Full Name
Grade Level
Public school building the child would attend if you had not chosen our school:
Child 4 Information (if applicable)
Full Name
Grade Level
Public school building the child would attend if you had not chosen our school:
Child 5 Information (if applicable)
Full Name
Grade Level
Public school building the child would attend if you had not chosen our school:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent/Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it.


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