APPLICATION FOR ENROLLMENT

St. Rita Catholic School 2010-2011

$150.00 Per Family Non-refundable Paid Y__ __N_ __

Are you a Saint Rita Parishioner? Yes No Number of years _______ Envelope #_______

Student information (Please print0 Entering Grade Fall 2010 _______

Child’s Legal Name Gender M____ F ____

_____________________/___ ____________/_____ _______________________

Last Name First Name Middle Name

Birth date _________/________/________ Place of Birth ______________________________

City State

________________________________________________________________________________
Address City State Zip

______________________________/__________________________/_______________________
Home Phone Number Cell Phone Mom Cell Phone Dad

_______________________ __/______ ____________________/___ _______________________

Social Security Number Child Social Security Number Mother Social Security Number Father

FAMILY INFORMATION

Father’s Name ___________________________________________________________________

First Middle Last

Father’s Occupation Business Phone E-mail

Father’s Religion _____________________ Father’s Place of Birth __________________________

Mother’s Name__________________________________________________________________
First Maiden Name Last

Mother’s Occupation Business Phone E-mail

Mothers Religion _____________________ Mother’s Place of Birth __________________________

Parents are: _____Married _____Divorced _____Single _____Separated _____Widowed

Child lives with ________ Mother & Father ________Mother only ________Father only

Other Please specify______________________________________________________________

Language spoken in the home______________________________________________________

Is your child currently attending school? YES NO Grade______________

If Yes, School _____________________________________/____________________ _____

Name Phone Number

________________________________________________________________________________
Address City State Zip Code

Is this student currently receiving: Has this student ever received:

Special Education Yes No Special Education Yes No
Related Services Yes No Related Services Yes No
(Speech, counseling, etc.)

Please specify these services: _______________________________________________

For a new student entering above the first grade, please be prepared to present recent report
cards and progress reports.

Both parents are asked to sign (if possible)

Father or Guardian_________________________________________________Date__________

Mother or Guardian________________________________________________Date__________

SACRAMENTAL INFORMATION

__________________________/____________________________/_________________________
Baptism Date Name of Church City & State

________________________ /_____________________________/_________________________
1st Communion Date Name of Church City & State