Application For Enrollment 2010

APPLICATION FOR ENROLLMENT St. Rita Catholic School 2010-2011 $150.00 Per Family

Non-refundable

Paid Y__

Are you a Saint Rita Parishioner? Yes No

__

__N_

Number of years _______ Envelope #_______

Student information (Please print0

Entering Grade Fall 2010 _______

Child’s Legal Name

Gender M____

_____________________/___

____________/_____

Last Name

First Name

Birth date _________/________/________

F ____

_______________________ Middle Name

Place of Birth

______________________________ City

State

________________________________________________________________________________ Address

City

State

Zip

______________________________/__________________________/_______________________ Home Phone Number

Cell Phone Mom

Cell Phone Dad

_______________________ __/______ ____________________/___ _______________________ Social Security Number Child

Social Security Number Mother

Social Security Number Father

FAMILY INFORMATION Father’s Name ___________________________________________________________________ First

Father’s Occupation

Middle

Last

Business Phone

Father’s Religion _____________________

E-mail

Father’s Place of Birth __________________________

Mother’s Name__________________________________________________________________ First

Mother’s Occupation

Mothers Religion _____________________

Maiden Name

Business Phone

Last

E-mail

Mother’s Place of Birth __________________________

Parents are: _____Married _____Divorced _____Single _____Separated _____Widowed Child lives with ________ Mother & Father ________Mother only ________Father only Other Please specify______________________________________________________________ Language spoken in the home______________________________________________________ Is your child currently attending school?

YES

NO

Grade______________

If Yes, School _____________________________________/____________________ Name

_____

Phone Number

________________________________________________________________________________ Address

City

Is this student currently receiving: Special Education Yes No Related Services Yes No (Speech, counseling, etc.)

State

Zip Code

Has this student ever received: Special Education Yes No Related Services Yes No

Please specify these services: _______________________________________________ For a new student entering above the first grade, please be prepared to present recent report cards and progress reports. Both parents are asked to sign (if possible) Father or Guardian_________________________________________________Date__________ Mother or Guardian________________________________________________Date__________ SACRAMENTAL INFORMATION __________________________/____________________________/_________________________ Baptism Date Name of Church City & State ________________________ /_____________________________/_________________________ 1st Communion Date Name of Church City & State