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!