Office Use Only (Circle)

Reg Fee $50 $60 $65 $75 ________

FHC Fee – Level 2: $15

Paid Y N Cash Check

Other Fee Due__________

Reg by__________Date__________

St. Mary’s

Religious Education

RE-REGISTRATION FORM 2008-2009

_____________________________

1^st CLASS CHOICE LEV. ___ DAY ___

2ND CHOICE DAY ____________

___ADDRESS/PHONE CHANGE

____I CAN VOLUNTEER IN THE PROGRAM.

STUDENT INFORMATION

FIRST NAME___________________________NICKNAME__________________BIRTHDATE______/_____/______ SEX M - F

LAST NAME________________________________________________SCHOOL ATTENDS________________

SCHOOL GRADE IN SEPTEMBER 2008__________ LEVEL COMPLETED IN R.E._______________________

SPECIAL MEDICAL CONDITION/MEDICATIONS_________________________________________________________________________________

PROCEDURE TO FOLLOW IF CONDITION PRESENTS AN EMERGENCY______________________________________

______________________________________________________________________________________________________

LEARNING DISABILITY HELD IN CONFIDENCE ________________________________________________________________________

INDICATE HYPERACTIVITY, ADD, ADHD, READING ETC.

CHILD LIVES WITH ____________________________________________________________________

PARENTS, MOTHER-STEPFATHER, FATHER-STEPMOTHER, GRANDPARENTS ETC.

FAMILY INFORMATION FAMILY NAME____________________________________________________

FATHER’S FIRST NAME___________________________LAST NAME________________________ RELIGION________

MOTHER’S FIRST NAME___________________________ LAST NAME______________________ RELIGION_________

ANY CHANGE IN MARITAL STATUS________________ MAIDEN NAME____________________________

HOME ADDRESS_________________________________________________________________________________________

STREET CITY ZIP

HOME TELEPHONE___________________UNLISTED Y N CELL NO.___________________ IS ADDRESS/PHONE NEW_____

FAMILY E MAIL ADDRESS:_________________________________________________

FATHER’S OCCUPATION______________________________________________TELEPHONE/CELL________________________

MOTHER’S OCCUPATION_____________________________________________TELEPHONE/CELL________________________

EMERGENCY CONTACT_______________________________________________________________________________________

NAME TELEPHONE

STEP PARENT NAME_________________________________DATE OF BIRTH__________RELIGION______

OTHER CHILDREN- Name_____________________________Date of Birth_____/______/_______

_____________________________ ____/____/____

_____________________________ ____/____/____

______________________________ ____/____/____

MEDICAL INFO_______________________________________________________________________________________________

NAME: DOCTOR-PHONE DENTIST-PHONE HOSPITAL

IF I CANNOT BE REACHED I GIVE PERMISSION FOR MY CHILD TO RECEIVE EMERGENCY MEDICAL ATTENTION

____________________________________________________________________________ Parent Signature