REGISTRATION FORM FOR SCHOOL AND EXTENDED CARE

Family Information
Primary Address
Primary Address
Located in?
required for state reporting
required for state reporting
required for state reporting
Secondary Address, if applicable
Secondary Address, if applicable
Catholic?
Children Registering for St. Roch
oldest child first, then descending order
Child 1 *
Child 1
Birthdate
Birthdate
registering for grade
Child 2
Child 2
Birthdate
Birthdate
registering for grade
Child 3
Child 3
Birthdate
Birthdate
registering for grade
Child 4
Child 4
Birthdate
Birthdate
registering for grade
Child 5
Child 5
BIrthdate
BIrthdate
registering for grade
Child 6
Child 6
Birthdate
Birthdate
registering for grade
Contact Information
Parent(s) must provide information used for emergency situations. Business information will not be shared - it is for school office use only. PLEASE DENOTE NEW OR CHANGED ITEMS FROM PREVIOUS YEAR WITH AN *
Parent 1 : Name
Parent 1 : Name
Parent 1: Cell Phone
Parent 1: Cell Phone
Parent 1: Work Phone
Parent 1: Work Phone
Parent 2: Name
Parent 2: Name
Parent 2: Home Phone
Parent 2: Home Phone
Parent 2: Cell Phone
Parent 2: Cell Phone
Parent 2: Work Phone
Parent 2: Work Phone
Emergency Contact Information
neighbor or relative that can be contacted in case of an emergency (illness or disaster) when parents can't be reached
Emergency Contact 1: Name
Emergency Contact 1: Name
Emergency Contact 1: Address
Emergency Contact 1: Address
Emergency Contact 1: Phone
Emergency Contact 1: Phone
Emergency Contact 2: Name
Emergency Contact 2: Name
Emergency Contact 2: Address
Emergency Contact 2: Address
Emergency Contact 2: Phone
Emergency Contact 2: Phone
Medical Information
Doctor's Name
Doctor's Name
Doctor's Phone
Doctor's Phone
Please list any allergies, medications, or medical conditions.. Be sure to include the child's name.