ST. ROSE OF LIMA

EXTENDED DAY PROGRAM

FAMILY REGISTRATION FORM

FAMILY NAME 

HOME ADDRESS
                                     Street                                     City

HOME PHONE ( )

NAMES OF CHILDREN

GRADE

GRADE

GRADE

GRADE

MOTHER�S NAME  FATHER�S NAME

HOME ADDRESS    HOME ADDRESS

TELEPHONE   TELEPHONE

BUS ADDRESS     BUS. ADDRESS

BUS. PHONE     BUS. PHONE

IMPORTANT:     GIVE THE NAMES OF TWO RELIABLE ADULTS WE MAY CONTACT IN CASE OF AN EMERGENCY IF NEITHER PARENT CAN BE REACHED:

NAME RELATION    PHONE

NAME RELATION  PHONE

Are parents separated?  Yes      No                            Divorced?    Yes       No

If so, with which parent does child live?

When your child is not scheduled for EDP, how will he/she go home? (check one)

Car rider           Bus #         Walker               Main Street                South Street 

Please give us the names of those individuals permitted to pick up your child.

PLEASE CHECK HERE IF YOU HAVE INCLUDED ANY IMPORTANT INFORMAT1ON ON THE BACK OF THIS FORM THAT WOULD BE HELPFUL TO US IN KEEPING YOUR CHILD HAPPY/HEALTHY UNTIL THEY ARE BACK WITH YOU!