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:

Parish in which Family is Registered: