Saint Rose of Lima
Religious Education/Faith Foundation
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Office Use Only Date Rec'd ______________ REGD _______________________ Baptism Cert.
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CLASSGN_________________ Transcript Rec'd ____________ |
KINDERGARTEN (FROM 9:30 – 10:45 am – Saturday)
2009 – 2010 Click here for page 2
STUDENT’S LEGAL
NAME
Last First
NICKNAME GENDER Check one: Male Female
ADDRESS HOME #
CITY STATE ZIP
MOTHER’S NAME FATHER’S NAME
MOTHER’S MAIDEN NAME
GUARDIAN NAME IF DIFFERENT FROM PARENT
STUDENT’S
D.O.B. PLACE
OF BIRTH
City
State
PUBLIC SCHOOL STUDENT WILL ATTEND SEPT. 2009
PUBLIC SCHOOL GRADE LEVEL IN SEPT. 2009
DOES
HE/SHE HAVE ANY LEARNING CHALLENGES AND/OR SPECIAL NEEDS?
PLEASE INCLUDE CLASSIFICATION
PLEASE SPECIFY ANY ALLERGIES TO MEDICATION / BEE STINGS AND/OR FOODS
DOES HE/ SHE HAVE ANY MEDICAL CONDITION? IF SO, SPECIFY
ARE THERE ANY OTHER SPECIAL INSTRUCTIONS? (i.e. dismissal, transportation, etc.)
DOES HE/ SHE HAVE ANY MEDICAL CONDITION, IF SO SPECIFY
ARE THERE ANY OTHER SPECIAL INSTRUCTIONS? (i.e. dismissal, transportation, etc.)