Child’s First Name: _____________________ Last Name: _____________

Name you wish your child to be called: _____________________________

Home Address: ________________________________________________

Community: _______________ State: _________ Zip Code: ____________

Date of Birth: ______________ Sex: __________ Race: _______________

Religion: _________________________ Parish/Church: _______________

Attendance: 3  or 5 days?            Will they need AfterCare?  yes    or no

Marital Status: Married _____ Divorced _____ Widowed ___ Single ____

Father’s Name: _________________________ Home Phone: ___________

Place of Employment: _____________________ Work Phone: __________

Mother’s Name: _________________________ Home Phone: __________

Place of Employment: _____________________ Work Phone: __________

Persons to contact in case of emergency: (other than parents)

Name: __________________________________ Phone: ______________

Name: __________________________________ Phone: ______________

Persons authorized to pick up my child: (other than parents)

Name: __________________________________ Relationship: __________

Name: __________________________________ Relationship: __________

Child’s Name: _________________________________________________

Doctor’s Name: _________________________ Phone: ________________

Please list any allergies or conditions, which may require special attention while your child is at school.

Allergies: _____________________________________________________

Other: _______________________________________________________

Has your child EVER had a seizure? _______________________________

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Our Lady of Lourdes Kindergarten has my permission to authorize medical attention to my child in the event that I cannot be contacted.

_______________________________

Parent’s Signature

Tuition and Fees Agreement - must be signed and attached to registration form in order for enrollment to be valid. Registration for Kindergarten and AfterCare must be paid for enrollment to be valid.

Copy of Birth Certificate MUST be on file to complete registration.

*In order to qualify for the discounted rate, each family must have a signed "Confirmation of Church Membership" form on file.

OLLK Use Only:

_____ Registration fee paid

_____ Birth Certificate on file