Name of Student(s)

Name of Parent

How long have you been a parishioner?

If not a parishioner, where do you attend church?

Address

Phone

Cell Phone

Students Birthdate (Month/Day/Year)

Students grade as of June 2011

Emergency Contact name and phone number

Allergies to medication or foods

Child's Physician

Physician's Phone

$7.00 registration fee is due for every student (no more than $20 per family).

Payment is due no later than June 1. Please check one of the following:

Additional Comments:

E-mail Address (optional)