|
St. Rose of Lima School Registration Form 2013-2014
Family information:_____________________________________ (Family Last Name)
Is your family: A registered member of St. Rose Church________ Not currently a member____
Father’s name______________________________
Mother’s name_____________________________
Step-Parent(s) name_________________________
Home address for student_______________________________________________
Parent address (if different):______________________________________
Home Phone____________________________________
Cell Phone - Father ______________________Cell Phone - Mother________________________
E-Mail Address____________________________________________________
Work Phone/Father_______________________ Work Phone /Mother________________
Insurance Provider/Policy Group Number________________________________
Does this student have any life-threatening medical condition that would necessitate medication, injection or other treatment to prevent death? If yes, please explain condition on the back of this form. _______yes _______no
Student to be enrolled
Name (first, middle, last) ________________________________ Grade______________
Birth date: _____________________ Place of Birth_________________________ Year and Church of Baptism: ____________________________________
First Communion: __________________ First Reconciliation: _______________
For our records, please include the names and ages of the student’s siblings not currently enrolled at St. Rose School.____________________________________________________
Book Fee ($235.00):
Date Paid _____________ Continued on back
Medical conditions/physical /mental limitations which the school needs to be aware of:
St Rose of Lima School staff is committed to meeting the needs of all students, in so far as possible. There are some conditions, however, for which the school cannot provide the necessary resources.
|