2006-2007 PSR Registration 

REGISTERING FOR: PSR______     PRESCHOOL______

STUDENT INFO

   LAST NAME:_________________________

   FIRST NAME: ____________________________ 

   MIDDLE NAME: _____________________________

   SEX:     ________

   ADDRESS:  ________________________

   CITY, STATE, ZIP:  ___________________

   PHONE:  ____________    Circle if UNLISTED   

   CELL PHONE:_______________

   BIRTH DATE:      _______________________

   CITY OF BIRTH:  ________________________

SCHOOL :   _____________________ 

   GRADE OR PRESCHOOL YR ENTERING: _____

   SPECIAL NEEDS (Illness, Disabilities, etc.):         

   __________________________________________________________

   BAPTISM DATE: ________________

BAPTISM CHURCH & CITY:  _______________  

FIRST COMMUNION CHURCH & YEAR:      ____________

   FIRST CONFESSION MADE:   Yes      No   (circle one) 

PARENT INFORMATION

   MOTHER:  _____________________  

   MAIDEN LAST NAME:  ____________________

   FATHER:  ______________________

   STEP PARENT OR GUARDIAN:  ___________

   FAITH OF MOTHER:  ________________

   FAITH OF FATHER:  _________________

   FAITH OF STEP PARENT OR GUARDIAN:   __________

   WHO DOES CHILD LIVE WITH:  ______________________

   RELATIONSHIP TO STUDENT:  ___________________

   ARE PARENTS REGISTERED AT ST. JUDE:      Yes    No    (circle one)