SAINT MARY EARLY LEARNING CENTER

Application/Registration Form 2012-2013

Child's Name _________________________________________________________________________Nickname _______________________ Sex____________

Last First Middle

Date of Birth_________________________________ Circle one: African American Caucasian Hispanic Asian Other_____________________

Mailing Address______________________________________________ Zip__________________ Home #____________________ Cell #__________________

Father's Name________________________________________________________________ Religion_____________________ Living?____________________

Family First Middle

Occupation___________________________________________ Company_____________________________________ Work #___________________________

Mother's Name________________________________________________________________ Religion____________________Living?____________________

Family First Middle

Occupation___________________________________________ Company______________________________________Work#___________________________

Parents Separated?___________ Child Lives with (circle)-- Mother Father Both Legal Guardian

Church Parish_______________________________ Email Address_____________________________________________________________________________

List brothers and sisters, their ages, and the school they are presently attending, if any:

Name Age School Attending Name Age School Attending

1._____________________ ______ ________________________ 3._______________________ ______ _________________________________

2._____________________ ______ ________________________ 4._______________________ ______ __________________________________

Person(s) to contact in case of emergency

if parents cannot be reached______________________________________________________________________ Phone #___________________________

Child's Physician_____________________________________________________________________ Phone #______________________________________

The following information is being requested so that we may better meet the needs of your child. Please answer the following questions. should you answer yes to any of the questions, please provide an explanation in the space provided.

1. Does your child have a chronic illness or disease? No Yes,__________________________________________________________

2. Does your child have a physical handicap? No Yes,__________________________________________________________

3. Do you think your child may have a vision/hearing problem? No Yes,__________________________________________________________

4. Are there any restrictions, for medical reasons, on your child's activities? No Yes,__________________________________________________________

5. Does your child require prescribed medicine daily? No Yes,__________________________________________________________

6. Does your child have any allergies to food? No Yes,__________________________________________________________

7. Does your child have any other allergies that we should know about? N o Yes,_________________________________________________________

Please indicate which class you would like your child to enter (mark first two choices):

FOUR-YEAR OLDS: THREE-YEAR OLDS: TWO- YEAR OLDS:

______Five mornings per week ______Two mornings per week ______Two mornings per week

______Three mornings per week ______Three mornings per week

______Five mornings per week ______Five mornings per week

***The following materials are needed to complete registration:

Child's Immunization Records

Child's Birth Certificate

Completed Parishioner Verification Form signed by the Pastor (to qualify as a Parishioner and waive the Building Usage Fee)

Saint Mary Early Learning Center*419 Doucet Road*Lafayette, Louisiana 70503*(337)984-3750*FAX:(337)984-8442