APPLICATION

3 yr. old ______  4 yr. old ______

3-day program ______  5-day program ______

Child’s Name: _____________________________  Sex: ______ DOB: ______

Address: ________________________ Zip: __________ Phone: __________

Parishioner of: ____________________ Religion: ______________________

Father’s Name: __________________ Religion: ________ Marital Status: _____

Address, if different: _________________________ Phone/Cell: ____________

Employer: ______________________ Occupation: ______________________

Mother’s Name: __________________ Religion: ________ Marital Status: _____

Address, if different: _________________________ Phone/Cell: ____________

Employer: ______________________ Occupation: ______________________

Mail should be addressed to whom? ___________________________________

Name of Public School District of Residence: _____________________________

Baptism: Date: _________ Church: ______________ City, State: ____________

Please indicate child’s race with an “X”

White Caucasian: ____    Black: ____    Bi-racial: ____    Hispanic: ____

Asian/Pacific: ____    American Indian: ____    Alaskan Native: ____

Siblings of Student:

Name: __________________________________ Age: ________

School Attending: __________________________ Grade: ______

Name: __________________________________ Age: ________

School Attending: __________________________ Grade: ______

Name: __________________________________ Age: ________

School Attending: __________________________ Grade: ______

Legal guardianship, custody papers or restraint orders must be kept on file in the office.

Emergency Contact (in the event neither parent can be reached):

Name: ________________ Relationship: __________ Phone/Cell: ____________

Name: ________________ Relationship: __________ Phone/Cell: ____________

Name: ________________ Relationship: __________ Phone/Cell: ____________

Office Use:

Reg. Fee ________

Supply Fee ______