Birth date: [month/day/year]________________________________________________

Grade child will enter in Sept. 2005: ___________________________________________

Has child been baptized: Yes/No       
Date:____________
Church Name & City/State: ________________________________________________
Has child received first communion? Yes/No
Date: Church Name & City/State: ___________________________________________

Has child been confirmed? Yes/No
Date:_______
Church Name & City/State: ________________________________________________

Mother's Name: ________________________
Father's Name: _________________________
Address: ____________________________________
Phone: _______________

With Whom Does Child Reside? Both Parents/Mother/Father

Does child have any special needs? (Hearing impaired, speech impaired, hyperactivity, etc.)
If yes please note: ___________________________________________________________

___________________________________________________________________________