Application for Enrollment

There is a $10.00 non-refundable application fee.

Preferred Start Date_____________

Name of Child_______________________Child goes by:_____________Gender ______

Child’s Address _________________________(city) ____________(zip code) _________

Date of Birth or Due Date: _____________________

Were there any complications at birth? Please briefly describe:

____________________________________________________________________________

Date and Parish of Baptism:______________________
Can your child do the following? Check all that apply.

Walk? ___

Drink from a sippy cup? ___

Drink from a regular cup? ___

Wear Pull Ups?___

Use the toilet with assistance?___

Use the toilet independently?___

____________________________________________________________________________________________ Parent Information:

Name of Mother:__________________________________________________

Employer and Occupation:__________________________________________

Name of Father: __________________________________________________

Employer and Occupation:__________________________________________

Phone Number(s) for Mother: cell_____________________work:_____________

Phone Number(s) for Father: cell_____________________ work:_____________

Email Address(most frequently used):__________________________________

Are you a registered member of St. Bede or other church? Please name: ________________________