Child Care / Student Census Count

Please complete the following as it pertains to your location by February 1. This questionnaire is being sent to all schools. The information is needed to continue to provide Student Accident Medical Insurance.

Required fields are marked with a *

School Information

School Name*

Unit No.*

Address*

City*

Zip*

Child Care Programs

Does your location provide child care, day care, or latchkey type programs?*

Include only parish/school sponsored and operated programs, not programs operated by third parties or child care provided during religious services. Yes No

If yes, please indicate the number of children participating in each program:

Preschool

Pre-K

Latchkey

Other

Student Enrollment

Please indicate the number of students enrolled in each grade level:

K through 8

9 through 12

Interscholastic Sports

Please indicate the number of students participating in Interscholastic Sports Programs:

Students who participate in more than one sport are to be counted only once. Do not include intramural sports.

K through 8

9 through 12

Completed By

Your Name*

Your Phone Number*

Your School Email*

As always, please do not hesitate to call 1-800-395-5565 or email riskmanagement@micatholic.org if you have any questions or concerns.

New Way to File a Claim

School Information

Child Care Programs

Student Enrollment

Interscholastic Sports

Completed By