Saint Rose of Lima 
Religious Education/Faith Foundation

Office Use Only                                                                               Office Use Only

Date Rec'd ______________                                                           REG'D _______________________

Baptism Cert. _____________                                                         CLASSGN_________­­­____­­­____
Recon. Cert. ______________
Eucharist Cert. _____________                                                        VTP - Yes _____ No _____

Transcript Rec'd ____________                                                   

STUDENT REGISTRATION FORM 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.)