Student's Name *:

Student's Age *:

Grade in School *:

Home Address *:

City *:

State *:

Zip *:

Home Phone:

Primary Contact's Name (Parent/Guardian) *:

Primary Contact's Cell Phone:

Primary Contact's Email Address *:

Secondary Contact's Name (Other Parent/Guardian):

Secondary Contact's Cell Phone:

Secondary Contact's Email Address:

Child's Place & Date of Birth *:

Church of Baptism, Location & Date *:

Baptismal Certificate Submitted?  Yes No

Sacraments:

First Eucharist:  Yes No

Confirmation:  Yes No

Prior Grades of Religious Education:

Name and Location of Prior Religious Education School:

Student Special Needs:

Parish in which Family is Registered: