_____________                                                                                       _________________
Application                                                                                              Entered in Computer
Date                                                                                                        

                                                                                                                _________________

Received Payment__________                                                                  Teacher

Rec #______________

Check#_____________

Name:______________________________________________________________________

               FIRST               FULL MIDDLE                                   LAST

Home Address:_______________________________________________________________

City:______________________________ Zip:_________ Home Phone:  _________________

Date of Birth: ____/___/______(Month/Day/Year)                                                      

FEMALE:______________________   MALE__________________

New to Holy Family Center:  Yes    No    (Circle One)*

If yes, prior religious education: _________________________________________________

Date of Baptism: ____/___/______(Month/Day/Year)*                               

Church of Baptism:__ ____________________________ City & State: __________________

Date of First Holy Communion____/___/______(Month/Day/Year)*

Church of Holy Communion:_______________________ City & State: ___________________

Special Needs:_____________________________ Learning Disabilities:_________________

Health Information/Allergies:___________________________________________________

Language spoken at home:_____________________________________________________

Mother's Name_______________________________________________________________

              FIRST                                FULL MIDDLE                             LAST

Father's Name_______________________________________________________________

              FIRST                                FULL MIDDLE                             LAST

Name of Parent responsible for receiving mail:_____________________________________

Church in which you are registered: (Check one of the 2 Parishes below)

______Most Holy Redeemer                   _______Sacred Heart Parish

In case of emergency and if we can't contact the parents first, please list two other responsible adults we should contact.

Name:_______________________________________ Relationship:___________________

Area Code and Phone Number:__________________________________________________

Name:_______________________________________ Relationship:___________________

Area Code and Phone Number:__________________________________________________

*Please note:  If it is your first year with the Holy Family Center, and your child received Baptism or First Holy Communion somewhere other than Sacred Heart or Most Holy Redeemer Parishes, you must present your child's Baptismal Record and/or First Communion Record.  We will be happy to make a copy and return the original to you.